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J7-2- 



GYNECOLOGY 



BY 

BROOKE M. ANSPACH, M.D. 

ASSOCIATE IN GYNECOLOGY, UNIVERSITY OF PENNSYLVANIA 



WITH AN INTRODUCTION BY 

JOHN G. CLARK 



m ILLUSTRATIONS 




PHILADELPHIA AND LONDON 
J. B. LIPPINCOTT COMPANY 






COPYRIGHT, 1921, BY J. B. LIPPINCOTT COMPANY 



Electroiyped and Printed by J. B. Lippincott Company 
The Washington Square Press, Philadelphia, U. S. A. 



APR 18 1921 
©CI.A611682 



TO 
JOHX G. CLARK, M.D. 

PROFESSOR OF GYNECOLOGY 
UNIVERSITY OF PENNSYLVANIA 



PREFACE 

Gynecology is to-day so broad a subject that in order to deal with it ex- 
haustively a series of monographs would be required. While monographs 
undoubtedly enrich the literature and are invaluable, they do not altogether 

!meet the needs of either the student or the practitioner of medicine, for in 
order to cover the necessary ground the student must of necessity be a 
voluminous reader, and he would be unusually discerning indeed if he 
were capable of selecting the pertinent from the unessential or the imma- 
terial. The monograph, moreover, does not furnish the needed information 
in such a form as to enable the practitioner to gather his facts with a reason- 
able expenditure of time. 

There would seem to be, therefore, a distinct place for the text-book 
which presents the subject in a systematic form, giving all the necessary 
information, and omitting such details as are not immediately required for 
practical purposes. A thorough acquaintance with the subject presented 
in this way will provide the student with a fund of information that clinical 
teaching and clinical experience will tend to crystallize and render appli- 
cable. In the library of the busy general practitioner the comprehensive 
text-book stands as a ready guide to the accurate diagnosis and the success- 
ful treatment of the gynecologic conditions most frequently encountered. 

A logical plan for studying the pathology of any organ or group of 
organs and of the methods of treatment may be formulated to include : (i) 
A description of the normal structures and of the normal functions ; (2) a 
review of the causes that produce the abnormal; and (3) a summary of the 
manifestations of the abnormal and of the methods of treatment. Believing 
this to be a rational sequence, the author has arranged and discussed the 
subject matter in the following order: (1) Normal anatomy and physiology; 
(2) morbid anatomy and physiologic abnormalities that are dependent upon 
developmental defects; (3) the acquired causes of disease of the reproduc- 
tive organs; (4) the general symptomatology, both subjective and objective, 
of diseases peculiar to the pelvic organs, together with the approved methods 
of investigation; and finally (5) a systematic arrangement and description of 
the diseases affecting the organs and structures of the entire generative 
tract — their morbid anatomy, symptomatology, diagnosis and treatment. 

In addition to affections of the generative organs proper, such diseases 
of the intestinal and urinary tract as are most frequently encountered in 
women have been considered. Static backache, sacroiliac sprain, toxic 
arthritis, gonorrhoea, tuberculosis, syphilis, menstrual disorders, sterility, the 
selection and preparation of operative cases, operative technic, post-operative 
treatment, and the management of post-operative complications, local thera- 
peutic measures, radium and Rontgen ray therapy, and the use of vaccines, 
have been dealt with under separate heads. 

Although seemingly superfluous in a work of this nature, the chapters on 
anatomy and physiology have been included in the belief that they will 



vi PREFACE 

serve to refresh the memory of the student and of the practitioner regarding 
the details of anatomy and physiology of the generative organs, a knowledge 
of which is so essential to a full understanding of gynecologic symptoms 
and operative treatment, and which will render unnecessary a search through 
the more exhaustive treatises devoted exclusively to these subjects. 

The author has drawn freely from the literature, and has aimed to give 
full credit for these quotations in the bibliographic references at the end of 
each chapter. The bibliography is intended to serve the student as a guide 
for more extended reading. Some of the earlier writings of the author have 
also been included. The majority of the illustrations have been made from 
original photographs or drawings. 

The author wishes to acknowledge his indebtedness to Dr. John G. 
Clark for the clinical and teaching experience that facilitated the prepara- 
tion of this volume. He is under especial obligations also to Dr. Philip F. 
Williams, who has reviewed the entire manuscript, criticising, correcting, and 
adding to the text, and assisting in many ways too numerous to mention. 
The suggestions of Dr. Charles C. Norris in the chapter on tuberculosis, 
of Dr. Frank Crozier Knowles in the chapter dealing with cutaneous lesions 
of the external genitalia, and of Dr. Floyd E. Keene in the chapter on exami- 
nation of the urinary tract, have been most acceptable ; Dr. Wm. J. Merrill 
and Dr. Frank Dickson have given assistance in the preparation of the chap- 
ter on backache ; Dr. Leon Jonas, in the section on acidosis ; and Dr. Henry 
Pancoast, in the chapter on radium treatment and Rontgen ray therapy. 

The author's thanks are also due to the artists, particularly Mr. Aitken, 
for the excellence of their work ; to the publishers, for their unfailing 
courtesy; to Miss Lilian B. Mendel, for careful editorial work; and to Miss 
Lydia Stieglitz, for her painstaking efforts in typing the manuscript. 

The Author. 
January, 192 i. 






CONTENTS 



CHAPTER PAGE 

I. Embryology i 

Embryologic Structures: Wolffian Body and Wolffian Duct, Mullerian 
Duct, Sexual Gland. Foetal Structures: Ovary, Uterus, Tubes, 
Vagina, External Genitalia, Bladder and Urethra, Rectum, Ureter 
and Kidney. Generative Organs at Birth and During Childhood: 
Ovary, Uterus, Tube, Vagina. Embryonic Rests and the New 
Formations Originating in them. 

II. Developmental Anomalies of the Generative Organs 15 

Morbid Anatomy: Ovary. — Absence of both; of one; rudimentary 
ovaries; supernumerary ovaries. Tubes. — Absence of both; of one; 
partial development; persistence of foetal type; supernumerary tubes; 
accessory ostia; diverticula. Uterus. — Complete absence; unicornis; 
duplex bicornis; duplex septus; bicornis; rudimentary; foetal type; 
infantile type; lateroposition; retroversion; retroflexion; anteflexion; 
stenosis of cervix. Vagina. — Complete absence; double; unilateral; 
atresia; septate. Hymen. — Atresia; double. Vulva. — Atresia or de- 
fectus; infantile. Bladder and Urethra. — Absence; double bladder; 
vesico-umbilical fistula; cyst of the urachus; epispadias; exstrophy of 
bladder; hypospadias. Ureter. — Duplication; absent; occlusion; ab- 
normal communications. Kidney. — Absent; rudimentary; foetal type; 
horseshoe; disciform. Anus and Rectum. — Complete absence of anus; 
imperforate anus; abnormally situated anus; partial and complete 
occlusion of the rectum; abnormal communications. Pseudohermaph- 
rodism. — Female; male. Gynatresia. — Forms; symptoms. Diag- 
nosis: External Genitalia; Uterus and Vagina, Imperfect, Double; 
Gynatresia. Treatment: Atresia Labia Minora; Hypertrophy of 
Clitoris; Hypertrophy of Labia Minora; Hypertrophy of Prepuce; 
Imperforate Hymen ; Rigid Hymen ; Epispadias ; Hypospadias ; 
Exstrophy of Bladder; Vaginal Adhesions; Atresia Vaginae, complete, 
partial; Vaginal Septa; Vaginal Stenosis; Hypertrophy of Cervix; 
Atresia of Cervix; Stenosis of Cervix; Infantile Uterus; Bicornate or 
Double Uterus; Hermaphrodism ; Gynatresia; Anus and Rectum. 

III. Anatomy of the Generative Organs 31 

Perineum: Vulva. Mons; Labia Majora; Labia Minora; Clitoris; 
Vestibule; Bartholin's Glands; Vestibular Bulbs. Vagina; uterus; 
tubes; ovaries; bladder; urethra; ureters; rectum; anus; the pelvic 
peritoneum; the uterine ligaments; the pelvic cellular tissue; the 
pelvic floor. Muscles. — Levator ani; coccygeus; pyriformis; trans- 
versa perinei; bulbo-cavernosi ; external sphincter ani; internal 
sphincter ani. Fascia. Blood-vessels of Pelvis: Arteries. — Ovarian; 
internal iliac; uterine; superior vesical; inferior vesical; vaginal ; superior 
hemorrhoidal; middle hemorrhoidal; inferior hemorrhoidal; internal 
pudic. Veins. — Ovarian ; uterine ; vesical ; internal pudic ; internal iliac ; 
obturator; superior hemorrhoidal; middle hemorrhoidal; hemorrhoidal 
plexus; inferior hemorrhoidal. Lymphatics of Pelvis: Pelvic Lymph- 
nodes. — Iliac; hypogastric; sacral; inguinal. Lymphatic Radicles. — 
From external genitalia; from ovary; from tube; from uterus, large 
fundal, small fundal, lower body and cervix; from vagina, upper, 
middle, lower. Abdominal Wall. 

IV. Physiology 61 

Reproductive Organs: Introduction. — Sexual maturity; nubility. 
Puberty. — Age; influences affecting; manifestations of puberty 
(psychical and physical) ; ovarian development. Functions of the Sex- 
ual Organs. — External genitalia ; internal genitalia ; glands of internal 
secretion; placenta; mammary glands. Menstruation. — Underlying 
impulse; phenomena of menstruation; menstrual flow; menstrual 
habit. Ovulation. — Rupture of follicle; corpus luteum; relation be- 
tween menstruation and ovulation. Anatomic changes incident to 



viii CONTENTS 

ovulation and mensturation. Fecundation. — Mechanics of insemi- 
nation; penetration of sperms to outer part of the tube. Nidation 
of the Ovum. — Decidua; chorion villi; trophoblast; intervillous 
blood spaces; placenta. Pregnancy. — Changes in uterus, fundus and 
cervix; tubes; ovaries (corpus luteum of pregnancy); vagina; ab- 
dominal wall; bladder. Labor. — Dilatation of cervix; formation of 
perineal gutter; dilatation of vaginal outlet; separation and expulsion 
of placenta; abortion or miscarriage. Puerperium. — Involution; struc- 
tures involved; residua indicative of pregnancy. Menopause. — Age; 
changes in ovaries; nervous manifestations; premature menopause; 
artificial menopause. Excretions of Genitalia. — Characteristics and 
source. Ureters: Excretion of Urine. — Gravity, peristalsis; back 
flow of kidney pelvis; back flow to ureter. Bladder: Free and fixed 
part of bladder; mechanics of retention and expulsion; reflexes in- 
volved. Rectum: Mechanics of defecation; reflexes involved. 

V. Causes of Pelvic Disorders 87 

Congenital: Appearing at Birth. — Gross malformations or tumors. 
Appearing at Puberty. — Gynatresia. Appearing During Reproductive 
Period. — Fibroid Tumor; sarcoma. Appearing at Menopause or 
After. — Ovarian tumors; carcinomata. Acquired: General Causes. — 
Anaemia; heart disease; mumps; tuberculosis; exanthemata of child- 
hood; defective development; bad hygiene; depressing conditions of 
body and mind; unnatural sexual state; unstable nervous system. 
Complicating Pregnancy and Labor. — Displacements; laceration. 
Cause of Malignant Growth. — Factors seeming to influence the de- 
velopment of cancer of vulva; cancer of vagina; cancer of cervix; can- 
cer of fundus; cancer of ovary. Infections. — Gonorrheal; puerperal; 
abortal. Bacteriology of Generative Tract. — Bacterial forms and 
peculiarities: Tuberculosis infection; gonococcus infection; strepto- 
coccus infection; staphylococcus infection. 

VI. History- taking and Symptomatology 91 

History: Attitude Toward Patient in Taking the History; Form of 
History Record; Chief Complaint; Age and Social State; Occupation 
and Habits of Life; Menstrual History; Pregnancies; Labor; Abortion; 
Family History; General Previous History; Onset of Present Trouble. 
Symptomatology: Present Symptoms. — Pain; location; quality. 
Menstrual Symptoms. — Amenorrhcea; menorrhagia; metrorrhagia, 
dysmenorrhoea. Leucorrhcea. — Amount; quality. Rectal Symptoms. — 
Constipation. Bladder Symptoms. — Frequency of urination; time of 
occurrence. Gastio-intestinal Symptoms; Respiratory Symptoms; 
Circulatory Symptoms; Nervous Symptoms; General Health. 

VII. General Physical Examination 103 

General Appearance ; Temperature ; Circulation ; Pulse Rate ; Exam- 
ination of the Heart; Respiratory Rate; Examination of the Lungs; 
Examination of the Blood; Blood Count; Blood Culture; Wasser- 
mann Reaction; Abderhalden Serum Test: Complement-fixation 
Test for Gonorrhoea; Obtaining Blood for Serum Tests; Exam- 
ination of the Urine. Bacteriologic Examination of the Urine; 
Recognition of Tubercle Bacillus by Guinea-pig Inoculation. 

VIII. Examination of the Pelvis and Abdomen 112 

General Consideration: Examination under Anaesthesia; Preparation 
for Examination. Positions for Pelvic and Abdominal Examination. — 
Dorsal; knee-chest; lithotomy; Sims'; supine; erect. Preparation of 
Physician's Hands. — Lubricant; gloves. Illumination. — Window; 
electric bulb. Instruments. — Specula, bivalve, trivalve, cylindric, 
rectal; vulsella; sound; dilators. Special methods of Examination; — 
Intrauterine digital palpation; Diagnostic Curettement and Test 
Excision. Smear Preparations as an aid to Diagnosis. Demonstra- 
tion of Treponema Pallidum. Pelvic Examination: Inspection. — 
External genitalia; vagina and cervix; pelvic viscera. Palpation. — 
Simple digital; bimanual; bimanual with cervix pulled down; 
bimanual with finger in rectum; trimanual palpation. Abdominal 
Examination: Inspection; Palpation; Percussion; Auscultation; 
Mensuration; Routine Examination of Remote Abdominal Organs. 



CONTEXTS ix 

IX. Examination of the Urinary Organs 158 

Urinalysis: Significance of constituents. Palpation: Urethra; blad- 
der; ureter; kidney. Percussion: limited field of usefulness. In- 
spection: Urethra; Urethroscopy; Bladder and Ureteral Orifices; 
Cystoscopy. Methods; general preliminaries. Technic of the Direct 
Method with Atmospheric Distention of Bladder. — Local anaesthesia; 
dilatation of meatus; position; removal of urine; locating fixed ana- 
tomical points; unusual appearances. Technic of the Indirect Method 
with Water Distention of Bladder. — Position; picture presented by 
normal bladder; alterations and significance thereof; in capacity of 
bladder; color and transparency of mucosa; number, size, and outline 
of vessels; shape of the vesical interior; submucous trabecular; posi- 
tion of the ureteral orifices. Catheterization of the Ureters: Technic 
with the Direct Method. — Preparation and introduction of catheters. 
Technic of the Indirect Method. — Facts determined by catheteriza- 
tion; examination of the ureter and kidney by means of a wax-tipped 
bougie; collecting urine. Rontgenographic-ray Examination of the 
Kidney: Diagnostic Methods Combining the Ureteral Catheteri- 
zation, collargol Injection, and the Rontgenographic-ray: Bismuth 
Catheter; Pyelography. Estimation of the Functional Activity of 
the Kidneys, Combined or Separate: Chromocystoscopy. — Indigo- 
carmine; chromo-ureteroscopy ; phenolsulphonephthalein. Blood Urea. 

X. Examination of the Anus and Rectum 162 

Preparation of Patient: Position. Inspection. — External, internal 
specula; Tuttle's, Kelly's', pneumatic proctoscope; appearance of 
healthy and of diseased bowel through the proctoscope; other useful 
instruments in making rectal examinations. Palpation. 

XI. Diseases of the External Genitalia 166 

Skin Diseases. — Cutaneous diseases; herpes; parasitic diseases. Vul- 
var Adhesions; Vulvitis; Gangrene; Pruritus; Kraurosis Vulvas; Ele- 
phantiasis. Venereal Sores. — Chancre; secondary syphilitic; tertiary 
syphilitic; chancroid; warts. (Edema; Varicose Veins; Hematoma; 
Hypertrophy; Carcinoma; Sarcoma; Tuberculosis; Rodent Ulcer; 
Fibromyoma; Lipoma; Sebaceous Cysts. Vulvovaginal Glands. — 
Inflammation of ducts; abscess; cyst. Injuries of the External Geni- 
talia; Pudendal Hernia. 

XII. Diseases of the Hymen and Vagina 192 

Hymen; Abnormal Rigidity or Elasticity of the Hymen; Cystic Tu- 
mors of the Hymen. Vagina; Vaginitis (Paravaginitis); Vaginismus. 
Cysts. — Fibromyoma; Sarcoma; Carcinoma; Chorioepithelioma. For- 
eign Bodies in Vagina; Leucorrhcea. 

XIII. Injuries to the Perineum and Their Results 200 

Physiology of Support of the Pelvic Floor; The Production of Injuries 
During Labor; Forms of Laceration and Their Result; Symptoms of 
Relaxed Perineum; Diagnosis; Treatment; Cystocele; Treatment. 

XIV. Diseases of the Cervix 223 

Atresia, Congenital and Acquired. — Causes: symptoms; treatment. 
Endocervicitis, Acute and Chronic. — Causes; symptoms; treatment, 
palliative and radical. Cervical Polyp. — Causes; symptoms; treat- 
ment. Laceration of Cervix; Secondary Lesions. — Eversion; Nabo- 
thian cysts. Hypertrophy of Cervix; Hypertrophy of Cervix in Nul- 
liparae. Symptoms of Lacerated Cervix. — Of simple; of complicated 
lacerations. Treatment of Lacerated Cervix; Indications for Opera- 
tion; Preparatory Local Treatment; Choice of Operation; Trachelor- 
rhaphy; Trachelectomy. 

XV. Changes in Form and Position of the Uterus 237 

Normal Flexion and Position. — Relations of axis of body to the axis 
of the cervix; normal flexion and position; exaggerated flexion in ill- 
developed stenotic cervix; subnormal flexion in chronic metritis. 
Pathologic Flexions and Positions. — Retroflexion; retroposition; 
latero-position and flexion ; anteposition in chronic metritis; descensus; 



CONTENTS 

prolapse; changes in the axis of the uterus in relation to that of the 
vagina, preceding downward displacement; elevation of the uterus. 
Pathologic anteflexion; Varieties; Symptoms. Treatment — Forcible 
dilatation; Dudley's operation; Pozzi's operation; Wy lie's drain; 
Norris drain; Metranoikter. Retroflexion and Retroversion; Causes; 
Pathology; Symptoms. Treatment. — Replacing uterus, use of pes- 
sary; operations, discussion of choice; technic of Alexander, ventro- 
suspension, ventral fixation; Coffey's operation; Webster-Baldy 
operation; Simpson's operation; shortening utero-sacral ligaments. 
Descensus of Uterus and Prolapse; Mechanics and Etiology; Ac- 
companying Lesions; Diagnosis. Treatment. — Pessaries, choice of 
operation; technic of vaginal fixation; Watkin's operation; supra- 
vaginal hysterectomy and fixation of stump. Anteposition; Elevatio 
Uteri; Torsion; Causes and Associated Conditions. Inversion. — 
Causes; symptoms; treatment. 

XVI. Diseases of the Endometrium and Myometrium 277 

Endometritis. Acute. — Causes; symptoms; diagnosis; treatment. 
Chronic. — Causes; conditions erroneously called chronic endometritis; 
symptoms; diagnosis; treatment. Endometrial Polyp. — Pathology; 
symptoms; treatment. Metritis. Acute. — Symptoms; treatment. 
Chronic. — Symptoms; diagnosis; treatment. Subinvolution. — Pa- 
thology ; symptoms ; treatment. Hyperinvolution. — Symptoms ; treat- 
ment. Perforation of the Uterus. — Causes; pathology; symptoms; 
treatment. Hematometra, Physometra, Pyometra. — Causes; symp- 
toms; treatment. Curettement, Curative and Diagnostic. 

XVII. Myomata of the Uterus; Adenomyoma 292 

Etiology and Histology: Vascularization of Myomata. Capsule, 
Number, Shape, Consistency; Situation. — Interstitial, Submucous, 
Subperitoneal. Migration of Myomata; Parasitic Tumors; Intra- 
ligamentous Myomata; Retroperitoneal; Subvesical. Growth; Dis- 
appearance. Pathology: Effect of Myomata on the Uterine Cavity 
and Wall; Effect of Myomata on the Appendages; Effect of Myomata 
on Bladder, Urethra, Ureters and Rectum; Effect of Myomata on 
Cardio-vascular System; Degenerations of Myomata. Symptoms. — 
Frequency; age of occurrence ; race; hemorrhage; pain; leucorrhcea; 
anasmia. Diagnosis. — Abdominal examination; bimanual palpation; 
submucous; interstitial; subperitoneal. Differential Diagnosis. — 
Ovarian cyst ; pregnancy. Treatment. — Palliative. Radical. — Choice 
of operation; myomectomy; abdominal; vaginal; hystero-myomec- 
tomy; pan-hysterectomy for myomata. Adenomyomata : Histology 
and Etiology; Pathology; Symptoms and Diagnosis; Treatment. 

XVIII. AIalignaxt Tumors of the Uterus 330 

Carcinoma of the Uterus. — Situation; etiology. Carcinoma of the 
Cervix. — Pathology; symptoms; diagnosis; "treatment; prognosis; 
the question of operability; treatment of inoperable cases; recurrence 
of carcinoma after operation. Carcinoma of the Body of the Uterus. — 
Pathology; symptoms; prognosis; treatment. Sarcoma of the Uterus. 
— Pathology; symptoms; diagnosis; treatment. Chorioepithelioma. — 
Pathology; symptoms; diagnosis; prognosis; treatment. Panhyster- 
ectomy for Malignant Tumors of the Cervix; Vaginal Hysterectomy 
for Malignant Tumors of the Cervix (Simple) ; Vaginal Hysterectomy 
for Malignant Tumors of the Cervix with Paravaginal Incision ; Cu- 
rettement and Cauterization ; High Amputation for Malignant Tumors 
of the Cervix with the Cautery Knife. 

XIX. Diseases of the Fallopian Tubes 359 

Inflammatory Disease. Salpingitis. — Etiology; pathology. Endosal- 
pingitis; Perisalpingitis; Interstitial Salpingitis; End Results of 
Endosalpingitis; Pyosalpinx; Tubo-ovarian Abscess; End Results of 
Perisalpingitis; Hydrosalpinx; Tubo-ovarian Cyst; Hematosalpinx; 
New Formations of the Tube; Polyps; Papillomata; Cysts of the 
Tubes; Myomata; Embryomata; Carcinoma; Symptoms, Diagnosis 
and Treatment of Affections of the Fallopian Tubes. Acciden ts Affect- 
ing Tubal Enlargements. — Rupture of pyosalpinx; rupture of hydro- 



CONTENTS xi 

salpinx; torsion of tubal enlargements; treatment. Extrauterine 
Pregnancy. — Etiology; varieties of extrauterine pregnancy; pathol- 
ogy. Nidation of Ectopic Ovum; Tubal Abortion and Tubal Rup- 
ture; Fate of the Ovum; Abdominal Pregnancy; Hemorrhage; Pelvic 
Hematocele; Free Intraperitoneal Hemorrhage; Uterine Changes in 
Extrauterine Pregnancy; Fate of the Pregnant Tube; Symptoms 
Previous to Tubal Rupture or Abortion; Symptoms at the Time 
of Rupture or Abortion; Symptoms Following Rupture or Abortion 
in Case of Abdominal Pregnancy; Prognosis; Diagnosis before Rup- 
ture; at Rupture or Abortion; Hematocele Formation; Abdominal 
Pregnancy; Treatment. 

XX. Diseases of the Ovaries 381 

Inflammation: Acute Interstitial Oophoritis. — Etiology; pathology. 
Acute Perioophoritis. — Etiology; pathology; end result of acute inter- 
stitial oophoritis; end result of acute perioophoritis; symptoms, diag- 
nos ; s, and treatment of inflammatory diseases of the ovaries. Chronic 
Oophoritis; Tumors of the Ovary; Epithelial; New Growths. Glandu- 
lar Cysts (Adenocystoma). — Etiology; pathology; symptoms; diag- 
nosis. Parovarian Cysts. — Etiology; pathology; symptoms; diagnosis. 
Papillomatous Cysts. — Etiology; pathology; symptoms; diagnosis. 
Carcinoma of the Ovary. — Etiology; pathology; symptoms; diagnosis. 
Connective Tissue New Growths: Fibromata, Fibromyomata. — 
Pathology; symptoms; diagnosis. Sarcomata. — Pathology; symp- 
toms; diagnosis. Combined Epithelial and Connective Tissue New 
Growths: Dermoid Cysts of the Ovary. — Etiology; pathology; symp- 
toms ; diagnosis. Treatment of Ovarian New Growths. Cystomata. — 
Uncomplicated glandular cystomata of the ovary; intraligamentous 
cysts; papillomatous cysts; cystoma complicating pregnancy. Car- 
cinomata; Fibromata; Sarcomata. Retention Cysts of the Ovary. 
Graafian Follicle Cysts. — Etiology. Hydrops Folliculi. — Etiology. 
Corpus Luteum Cysts. — Etiology; symptoms, diagnosis, and treat- 
ment of retention cysts. Compound theca-lutein cysts of the 
ovary. Accidents and Complications of Ovarian Tumors: Infection. 
— Etiology; symptoms; diagnosis. Torsion. — Etiology; symptoms; 
diagnosis. Rupture. — Etiology; symptoms; diagnosis. Malignant 
Degeneration. — Symptoms; diagnosis; treatment of accidents and 
complications of ovarian tumors. Atrophy of the Ovary; Hyper- 
trophy of the Ovary ; Hernia of the Ovary. Prolapse of the Ovary. — 
Cause; symptoms; diagnosis; treatment. 

XXL Pelvic Inflammatory Disease 41 1 

Pelvic Inflammatory Disease. — Classification; etiology; pathology. 
Gonorrhceal Pelvic Inflammatory Disease. — Etiology; pathology; 
symptoms; treatment. Puerperal Pelvic- Inflammatory Disease. — 
Etiology; pathology; symptoms; diagnosis; prognosis; end results; 
treatment. Instrumental or Post-operative Pelvic Inflammatory 
Disease. — Etiology; pathology; symptoms; treatment. Pelvic Ab- 
scess. — Definition; treatment. Chronic Pelvic Inflammatory Dis- 
ease. — Etiology; pathology; symptoms; diagnosis; treatment. Cellu- 
litis.— Etiology; pathology; symptoms; diagnosis; treatment. Chronic 
Pelvic Cellulitis. — Symptoms; diagnosis; treatment. Pelvic Hema- 
toma. — Etiology; pathology; symptoms; diagnosis; prognosis; treat- 
ment. Hysterectomy for Pelvic Inflammatory Disease; Salpingo- 
oophorectomy; Salpingectomy; Salpingostomy; Vaginal Incision and 
Drainage. 

XXII. Diseases of the Urethra 440 

Urethritis. — Causes. Acute. — Symptoms; diagnosis; prognosis; treat- 
ment. Chronic. Suburethral Abscess. — Cause ; symptoms; treatment. 
Fissure of Urethra. — Cause; symptoms; diagnosis; treatment. Pro- 
lapse of Urethral Mucosa. — Cause; symptoms; treatment. Dilata- 
tion of Urethra. — Cause; symptoms; treatment. Stricture of Urethra. 
— Cause; symptoms; diagnosis; treatment. Urethral Caruncle. — 
Symptoms; treatment. New Growths of Urethra. 



Xll 



CONTENTS 



XXIII. Diseases of the Bladder 453 

Cystitis. Acute Cystitis. — Etiology; symptoms; diagnosis; treatment; 
prognosis. Chronic Cystitis. — Etiology; symptoms; diagnosis; treat- 
ment. Tuberculous Cystitis. — Etiology; symptoms; diagnosis; treat- 
ment. Vesical Calculus. — Etiology; symptoms; diagnosis; treatment. 
Hunner Type of Bladder Ulcer in Women. New Growths of the Blad- 
der: Papilloma. — Symptoms; diagnosis; treatment. 

XXIV. Urinary Fistula 463 

Site and Varieties. Urogenital Fistula. — Etiology; symptoms; diag- 
nosis. Treatment. — Vaginal operations; extraperitoneal abdominal 
operations; nephrectomy. 

XXV. Diseases of the Kidney and Ureter 469 

Diseases of the Kidney. Ptosis; Abnormally Movable Kidney. — 
Etiology; symptoms; diagnosis; treatment. Hydronephrosis. — Con- 
genital, acquired; etiology; symptoms; diagnosis; differential diag- 
nosis; treatment. Pyelonephritis, Pyelonephrosis, Empyema of the 
Kidney Pelvis and Kidney Abscess. — Etiology; symptoms; diagnosis; 
treatment. Tuberculosis of the Kidney. — Etiology; pathology; symp- 
toms; diagnosis; treatment; prognosis. Renal Calculus. — Etiology; 
symptoms; diagnosis; treatment. Tumors of the Kidney. — Nature; 
symptoms; diagnosis; treatment. Cystic Tumors of the Kidney; 
Polycystic Disease of the Kidney; Adenocystoma; Adrenal Tumors; 
Pararenal Tumors; Kidney Operations; Nephropexy; Nephrotomy; 
Nephrolithotomy; Nephrectomy. Pyelitis. — Acute, chronic, etiology; 
symptoms; diagnosis; prognosis; treatment. Diseases of the Ureter. 
Inflammation. — Symptoms; diagnosis; treatment. Ureteral Calcu- 
lus. — Symptoms; diagnosis; treatment; operative treatment; stone 
in the upper ureter; stone in the pelvic brim; stone on the pelvic floor; 
stone in the vesical portion of the ureter; stone in the intraparietal 
ureter. Stricture of the Ureter. — Etiology; symptoms; pathology; 
diagnosis; treatment. Obstruction of the Ureter. — Symptoms; 
treatment. Ureteral Fistula; Ureteral Ligation; Ureteral Tear 
or Injury. 

XXVI. Diseases of the Abdominal Viscera Related to, or Associated 

with. Pelvic Disorders 500 

Introduction. Appendicitis. — Involvement of appendix in pelvic dis- 
ease; varieties of appendicitis. Acute Appendicitis. — Symptoms; 
diagnosis; differential diagnosis between acute appendicitis and acute 
adnexitis; history; symptoms; physical signs; course of the symptoms; 
treatment. Chronic Appendicitis. — Symptoms and diagnosis; dif- 
ferential diagnosis between chronic appendicitis and chronic adnexitis; 
treatment. Appendicectomy. — Interval operation; operation in acute 
cases: (a) Unruptured; (b) perforated appendix with spreading peri- 
tonitis; (c) appendicial abscess. Intestinal Stasis. — Acute, chronic. 
Varieties. — Chronic intestinal stasis from pelvic disease; chronic in- 
testinal stasis from enteroptosis; chronic intestinal stasis from ad- 
hesions between intestinal loops or between the intestine and the 
parietal peritoneum or the mesenteries or omentum; chronic intestinal 
stasis from redundancy and overdistention of the colon; symptoms; 
diagnosis. Treatment. — Gastropexy; colonopexy; release of adhesions; 
short-circuiting by intestinal anastomosis; resection of intestine; con- 
traction or expansion of the abdomen. Diverticulitis. — Etiology, 
symptoms; treatment. 



XXVII. Diseases of the Anus and Rectum 522 

Fissure in Ano. — Etiology; symptoms; diagnosis; treatment; divul- 
sion of the sphincter; operation for fissure in ano. Fistula in Ano. — 
Etiology; symptoms; diagnosis; treatment; operation for fistula in 
ano. Pruritus Ani. — Etiology; symptoms; diagnosis; treatment. 
Hemorrhoids. — Etiology; symptoms; diagnosis; treatment; operative 
treatment. Prolapse of the Rectum. — Etiology; varieties; symptoms; 
diagnosis; treatment. Tumors of the Rectum. Polyps. — Etiology; 



CONTENTS xiii 

symptoms; diagnosis; treatment. Carcinoma of the Rectum. — Loca- 
tion; etiology; symptoms; diagnosis; treatment. Stricture of the 
Rectum. — Etiology; symptoms; diagnosis; treatment. 

XXVIII. Backache 536 

Introduction ; Mechanics of Equilibrium. Static Backache. — Etiology ; 
symptoms; diagnosis; normal type; kangaroo type; gorilla type; differ- 
ential diagnosis; treatment; orthopedic treatment; mechanical treat- 
ment; gorilla type. Sacroiliac Sprain. — Etiology; symptoms; exami- 
nation; diagnosis; treatment; prognosis. Toxic Arthritis; Pendulous 
Fat Abdomen, Relaxed Abdominal Wall. Coccygodynia. — Etiology; 
symptoms; diagnosis; treatment. 

XXIX. Gonorrhoea 554 

General Peculiarities; Latent and Residual Gonorrhoea; Symptoms; 
Diagnosis; Technic of the Preparation and the Examination of Smears 
for the Gonococcus; Prognosis; Prophylaxis; Treatment of the Acute 
Initial Stage. 

XXX. Tuberculosis of the Generative Organs 560 

General Considerations; Incidence. Tubal Tuberculosis. — Symp- 
toms; treatment. Tuberculosis of the Peritoneum. — Pathology; 
symptoms; treatment. Tuberculosis of the Endometrium. — Symp- 
toms; treatment. Tuberculosis of the Ovary; Tuberculosis of the 
Cervix; Tuberculosis of the Vagina; Tuberculosis of the vulva. 

XXXI. Syphilis of the Generative Organs 569 

General Considerations; Mode of Infection; Pathology; Syphilis of the 
Vulva; Syphilis of the Vagina; Syphilis of the Cervix; Syphilis of the 
Uterus; Syphilis of the Tube; Syphilis of the Ovary; Syphilis of the 
Cellular Tissue; Diagnosis of Syphilis of the Generative Tract in 
Women; Differential Diagnosis of Syphilitic Lesions of the Cervix; 
Prognosis of Syphilitic Conditions of the Generative Tract in Women; 
Treatment. 

XXXII. Disorders of Menstruation 579 

Precocious Menstruation; Delayed Menstruation; Vicarious Men- 
struation; Amenorrhcea; Anatomical Defects Producing Amenorrhcea; 
Constitutional Diseases Producing Amenorrhcea; Psychic Influences 
Producing Amenorrhoea; Menorrhagia; Metrorrhagia; Dysmenorrhcea ; 
Dysmenorrhcea Due to Developmental Defects; Dysmenorrhoea Due 
to Acquired Lesions; Interval Dysmenorrhcea; Treatment of Dysmen- 
orrhcea; Membranous Dysmenorrhcea; Menopause; Premature Meno- 
pause; Artificial Menopause. 

XXXIII. Sterility 598 

Etiology; Imperfect Development of Genital Organs; Acquired Dis- 
eases; Functional Defects. Diagnosis. — Huhner's method. Treat- 
ment. — Ovarian transplantation; artificial insemination. 

XXXIV. Hygiene and the Relation Between Nervous and Gynecologic 

Disorders 609 

The Hygiene of Adolescence ; The Relation of Neuroses to Pelvic Dis- 
ease; Insanity in Its Relation to Gynecology. 

XXXV. The Selection and Preparation of Patients for Operation 613 

The Selection of Cases; The Examination and Treatment of Patients 
Preparatory to Operation; Cardiac Risks; Anaemia Risks; Blood-pres- 
sure Risks; Crile's Anoci Association-, Kidney Risks. 

XXXVI. Operative Technic 620 

General Preparation of the Patient. Preparation of the Operative 
Area. — Perineal operations; abdominal sections. Preparations of the 
Operator and Assistants; Preparation of Dressings and Utensils; 
Preparation of the Operating Room and Furniture; Preparation of 
Wash- Water; Preparation of Instruments; Ventilation and Lighting; 
Some General Points in Operative Technic to be Observed During 
the Operation. The Abdominal Incision. — Low paramedian celiotomy 



/ 



XIV 



CONTENTS 



incision; right or left lateral celiotomy incision; high paramedian celi- 
otomy incision; transverse suprapubic incision; gridiron incision. 
Kidney Incisions. — Kelly's incision; Mayo's incision for lumbar ex- 
posure of the kidney; Israel's incision; Mayo-Robson's incision. •Di- 
rections Regarding All Incisions; Isolation and Exposure of the 
Operative Area; Exploration of the Abdomen; Hemostasis; Adhesions; 
Wounds of the Viscera; Ligation of the Ureters; Treatment of Sur- 
faces Denuded as the Result of Separation of Adhesions; Closing the 
Incision; Dressing the Incision; Sponges and Pads Used in Abdominal 
Surgery. Anaesthesia. — Ether; chloroform; nitrous oxide and oxygen; 
nitrous oxide, oxygen and ether; anaesthesia by combined general 
and local methods; ethyl chloride. Local Anaesthesia; Solutions for 
Producing Local Anaesthesia. Technic of Producing Local Anaes- 
thesia by the Injection of Novocaine. — Celiotomy incisions; vulvar 
or vaginal incisions; cervix operation or hysterotomy. Local Anaes- 
thesia by Freezing with Ethyl Chloride; Spinal Anaesthesia in Pelvic 
Surgery; Multiple Operations; Operations During Pregnancy. Drain- 
age. — Gall-bladder and gall-ducts; pancreas; kidney; bladder. Post- 
operative Care in Drainage Cases. 

XXXVII. Post-operative Treatment 663 

Thirst; Pain Following Operation; The Diet; The Care of the Bowels; 
The Care of the Bladder; Enteroclysis; Posture After Operation; 
Fowler; Trendelenburg; Out of Bed; Dressing the Incision. 

XXXVIII. Post- operative Complications 670 

Shock. — Etiology; symptoms; treatment. Hemorrhage. — Varie- 
ties: capillary oozing; venous and arterial hemorrhage; hemorrhage 
after plastic operations; symptoms; diagnosis; treatment. 
Excessive Nausea and Vomiting. Tympanites. Peritonitis. — 
Etiology; symptoms; diagnosis; treatment. Intestinal Obstruc- 
tion. — Etiology; symptoms; diagnosis; treatment. Acute Gastric 
Dilatation. — Etiology; symptoms; diagnosis; treatment. Bron- 
chitis. Pleurisy. Nephritis. Suppression of Urine from Ureteral 
Obstruction. Phlebitis. Pulmonary Embolism. — Etiology; symp- 
toms; diagnosis; treatment. Post-operative Renal Infection. 
Suppuration of the Incision. Local Inflammation or Suppuration 
in the Pelvis. Cystitis. Post-operative Cardiac Dilatation. 
Post-operative Parotitis. Acidosis. 

XXXIX. Mechanical and Medicinal Aids to Treatment 696 

Abdominal Support: Binders and Bandages. — Binder; corsets. Ap- 
plications to the Endometrium; Applications to the Cervix; Applica- 
tions to the Vagina; Applications to Bartholin's Glands; Applications 
to the Urethra and Skene's Tubules; The Use of Heat in Pelvic In- 
flammatory Disease; Electricity; Pessaries; The Electro-cautery and 
the Thermo-cautery; The Uterine Pack; The Vaginal Douche; The 
Vaginal Tampon. 

XL. Radium and Rontgen-ray Therapy 713 

Radium; Carcinoma of the Cervix; Carcinoma of the Fundus; Myo- 
mata Uteri; Hemorrhagic Uteri; Carcinoma of the Vulva; Papillomata 
and Carcinomata of the Bladder; Rectal Diseases; Abdominal Tumors. 



XLI. Vaccine and Serum Therapy in Gynecology 725 

Specific Therapy; Auto-serum Therapy; Vaccine Therapy; dosage. 



ILLUSTRATIONS 



FIG. PAGE 

i . Schematic Outline Showing Development of Reproductive Organs 2 

2. Enlarged Schematic Wolffian Tubule at Height of Development 3 

3. Wolffian Bodies and Sexual Glands of a Human Embryo 3 

4. Schematic Solid Reconstruction of the Reproductive Organs 4 

5. Developing Ovary of Embryo 4 

6. Development of the Cervix and the Vagina 5 

7. Sketch Showing Formation of Bladder, Ureters, External Genitalia and Anus 5 

8. External Genitalia of an Embryo 18 mm. Long 6 

9. Indifferent Stage of External Genitals of Thirty-three- day Embryo 6 

10. External Genitalia of Female Embryo of Xine Weeks 6 

11. External Genitalia of Female Embryo of Eleven Weeks 6 

12. External Genitalia of Female Embryo of Sixteen Weeks 6 

13. Ovary of Xew-born Child 7 

14. Ovarv of Xew-born Child; Relationship of Ovarian Arterv to Ovarv, Tube and Uterus 7 

15. Ovary of Child Two Years Old " '. 8 

16. Ovary of Girl Nine Years Old 9 

17. Ovary of Girl Sixteen Years Old 10 

18. Reconstructive Drawing Showing Ovary of Young Woman in Active Menstrual Life 10 

19. Ovary of Woman Forty-two Years Old 11 

20. Contents of Pelvis in Embryo of Three and One-half Months 12 

2 1 . Fallopian Tube and Ovary 13 

22. Uterus Unicornis 15 

23. Uterus Didelphys 15 

24. Uterus Pseudodidelphys 16 

25. Uterus Duplex Bicornis 16 

26. L'terus Duplex Septus 16 

27. Uterus Duplex Subseptus 16 

28. Uterus Bicornis 17 

29. Uterus Bicornis, with Dwarfing of One Horn 17 

30. Double Vagina and Double Cervix 18 

31. Atresia of Vagina; Manner of Closing Wound After Removing Obstructing Septum. . 19 

32. Nearly Imperforate Hymen 20 

S3- Gynatresia; Bulging Imperforate Hymen, Simulating Large Cystocele 22 

34. Gynatresia; Imperforate Hymen 23 

35. Haematocolpos 24 

36. Haematotrachelos ; Haematocolpos 24 

37. Haematometra; Haematotrachelos; Haematocolpos 24 

38. Haematosalpinx ; Haematometra; Haematotrachelos: Haematocolpos 24 

39. Gynatresia of One-half of Double L'terus and Double Vagina 25 

40. Gynatresia of One L'terus and Haematometra in Double Uterus 25 

41. Division of Female Perineal Region Into L'rogenital and Rectal Triangles 31 

42. Xormal Virginal Vulva Showing Component Parts 32 

43. Histology of Various Parts of the Genital Tract 33 

44. Vaginal Fornices; Posterior Fornix; Anterior Fornix 34 

45. Sagittal Section Through Young Female Body 35 

46. Vaginal Wall; Stratified Squamous Epithelial Surface and Connective Tissue 36 

47. Anterior Aspect of Xulliparous Adult L'terus 36 

48. Posterior Aspect of Xulliparous Adult L'terus 36 

49. Lateral Aspect of Xulliparous Adult Uterus 37 

50. Transverse Section of L'terus at Fundus 37 

51. Transverse Section of L'terus Above Internal Os 38 

52. Para-sagittal Section of the Pelvis 38 

53. Histology of Cervix 39 

54. Histology of Endometrium of Body of L'terus 40 

55. Histology of Fallopian Tube 41 

56. Histology of Ovary 42 

57. Interior of Bladder and Relation of Ureter to Uterine Artery 44 

58. View of Pelvis From Above 46 

59. Lateral Sagittal Section of Female Pelvis 47 

xv 



xvi ILLUSTRATIONS 

60. Supporting Ligaments of Uterus; Their Relation to Other Pelvic Structures 48 

61. Frontal Section of Pelvis Through Urogenital Triangle - 49 

62. Semi-diagrammatic Picture Showing Course of Arteries, Veins and Lymphatics. ... 50 

63. Fascia of Pelvic Floor 51 

64. External Muscles, Fascia, and Structures of the Perineum 51 

65. Muscles of Pelvic Floor from Below 52 

66. Triangular Ligament in the Female 53 

67. The Pelvic Diaphragm from Above 54 

68. The Blood Supply of the Pelvic Viscera 55 

69. Anatomy of L^reter: Course in Pelvis and Relation to L'terine Artery 56 

70. Sagittal Section of Rectum : Hemorrhoidal Arteries, Veins and Lymphatics of Rectum 

and Anus 57 

7 1 . Blood-vessels of the Pelvis 58 

72. Lymph Vessels and Glands of Pelvic and Lumbar Regions 59 

73. 74, 75, 76. Mucous Membrane of Uterus in Various Phases of Menstruation 67 

77. Uterine Mucous Membrane in First Day of Menstruation 68 

78. Schematic Drawings, Showing Relation Between Ovulation and Menstruation 69 

79. Showing Collection of Blood Beneath Surface Epithelium, and Its Escape 70 

80. Showing Two Layers of Decidua of Second Month, Decidua Compacta and Decidua 

Spongiosa 71 

81. Showing Gland Duct of Decidua Compacta of the Second Month 72 

82. Drawing Showing Relative Size of Imbedded Early Ovum and L'terus 73 

83. Section Through Peters Ovum and Surrounding L'terine Mucous Membrane 74 

84. Summit of the Peters Ovum 75 

85. Chorionic Villus from the Second Month 76 

86. Human Ovum, Showing Chorionic Villi 76 

87. Anlage of Placenta from the Second Month 77 

88. Pregnant Icterus at Term 7> 

89. Pregnant Uterus at End of First Stage of Labor 7> 

90. Height of Fundus of Pregnant L'terus at Different Periods 7 s 

91. Softening of Lower L"terine Segment of Early Pregnancy 79 

92. Gradual Obliteration of Internal Os and Cervical Canal at End of Pregnancy 79 

93. Vaginal Wall Being Torn from Attachments and Pushed Forward 80 

94. Bilateral Laceration and Elongation of Anterior Lip of Cervix 80 

95. Distention of Perineal Muscles by Birth of Head 81 

96. Distention of Perineum Just Before Birth of Head s 2 

97. Atrophic Changes in a Senile ITterus with Shrunken Appendages 83 

98. Form of History 92 

99. Showing Positions of L'terus with Full Bladder or Rectum or Both 112 

100. Position of Uterus, with Distended Bladder and Rectum 113 

101. Dorsal or Lithotomy Position 114 

102. Knee-chest Position 115 

103. Sims' Position, Left Latero-prone Position 115 

104. Supine Position 116 

105. Showing Regions of Abdomen 116 

106. Sims' Speculum : . 117 

107. Bivalve and Tri valve Speculum; Collapsible Tube of Lubricant; Ultzmann Syringe 118 

108. Kelly's Urethral Speculum 119 

109. Double Tenaculum 119 

no. Long Thumb Forceps, L'terine Sound, Applicator, Spatula, Curved Dressing Forceps 120 

in. Goodell's Dilator 120 

112. Sims' Curette 121 

113. Martin's Curette 121 

114. Excision of Diseased Cervical Tissue for Microscopic Examination 122 

115. Inspection of External Genitalia: Expression of Discharge from Urethra 123 

116. Inspection of External Genitalia; Expression of Discharge from Bartholin's Glands 123 

117. Gonococci Stained in Smear 124 

118. Spirochaeta Pallida 124 

1 19. Exposure of Vagina and Cervix by Bivalve Speculum 125 

120. Digital Examination and Schematic Outline of Anteflexion 126 

121. Digital Examination and Schematic Outline of Retroflexioversion 126 

122. Digital Examination and Schematic Outline of Pelvic Mass 126 

123. Schematic Outline Showing Prolapsed Ovary Palpable on Digital Examination. ... 126 

1 24. Bimanual Examination ; Schematic Outline of Anteversion and Pathologic Anteflexion 1 2 7 

125. Bimanual Examination; Schematic Outline of Retroflexioversion 127 

126. Bimanual Examination; Schematic Outline of Pelvic Mass 128 









ILLUSTRATIONS xvii 

27. Simple Digital Examination; Schematic Outline of Prolapsed Ovary 128 

28. Position of Hands in Bimanual Examination of Pelvis 128 

29. Outline Showing Position of Fingers in Examination of Tube and Ovary 129 

30. Bimanual Examination with Uterus Drawn Down 129 

3 1 . Combined Recto-vaginal Examination 1 29 

32. Trimanual Examination, Case of Ovarian Cyst 130 

33. Lateral Aspect of Abdomen with Large Myomatous Uterus 131 

34. Anterior Aspect of Abdomen with Uterus Deviated to Right 132 

35. Anterior Aspect of Abdomen with Extreme Ascitic Distention 133 

36. Lateral Aspect of Abdomen with Extreme Ascitic Distention 133 

37. Lateral Aspect of Abdomen in Case of Large Ovarian Cyst 134 

38. Lateral Aspect of Abdomen in Case of Pregnancy Near Term 134 

39. Lateral Aspect of Abdomen in Case of Ovarian Cyst with Carcinomatosis 135 

40. Cross Section of Abdomen; Reason for Coronal Resonance 136 

41. Cross Section of Abdomen; Reason for Central Resonance and Lateral Dulness. . . . 136 

42. Trimanual Method of Percussion of Kidney 139 

43. Kelly's Improved Cystoscope 140 

44. Nitze Catheterizing Cystoscope 141 

45. Nitze Examining Cystoscope 141 

46. Cylindrical Jar for Sterilization of Cystoscopes 142 

47. Ureteral Catheter 143 

48. Sterilizing Ureteral Catheters 144 

49. Ureteral Calibrator 144 

50. Irrigating Apparatus 145 

51-152. Two-way Irrigator or Catheter; Top and Bottom Views 148 

53. Catheterization of the Ureter 149 

54. Rontgenogram of Ureteral Stone 151 

55. Shadows Cast by Vermiform Concretion and by Phlebolith 152 

56. Rontgenogram of Suspected Renal Calculus with Sound in Ureter 153 

57. Rontgenogram Showing Stone in Upper Calyx of Right Kidney 154 

58. History in This Case Indicated Ureteral Calculus 155 

59. Rontgenogram Failed to Demonstrate a Calculus 157 

60. Ptosis of the Left Kidney with Hydronephrosis 158 

61. Examination of Rectum; Patient in Dorsal Position with Tuttle's Pneumatic 

Speculum 1 62 

62. Examination of Anus, Buttocks Separated 163 

63. Tuttle's Pneumatic Speculum 163 

64. Kelly's Proctoscope 164 

65. Examination of Rectum and Lower Sigmoid with Proctoscope 164 

66. Kelly's Sigmoidoscope 165 

67. Elephantiasis of Vulva 172 

68. Chancre of Vaginal Introitus 173 

69. Gumma of Vulva, with Secondary Infection and Ulceration 174 

70. Condylomata Lata, Secondary Syphilis, Surrounding Vulva (in Color) 174 

71. Condylomata Lata of the Vulva and Anus 175 

72. Syphilis (Secondary) of the Vulva and Anus 176 

73. Syphilis (Secondary) of the Vulva and Anus 177 

74. Syphilis (Secondary) of the Vulva and Anus 178 

75. Gumma of the Vulva, Tertiary Syphilis 179 

76. Chancroid 180 

77. Venereal Warts 181 

78. Varicose Veins of the Vulva 182 

79. Haematoma of Vulva 183 

80. Epithelioma of Vulva, Indurated Fungoid Ulcer 184 

81. Lupus of Vulva, a Pre-ulcerative or Infiltrative Stage 185 

82. Sarcoma of Left Labium Minus 186 

83. Fibromyoma of Vulva (in Color) 186 

84. Lipoma of Right Labium Majus 187 

85. Abscess of Left Vulvovaginal Gland 188 

86. Extreme Cystic Distention of Vulvovaginal Gland 189 

87. Cyst of the Posterior Vaginal Wall 194 

88. Sarcoma of Vagina in Child Two and One-half Years Old 195 

89. Case of Adenocarcinoma of Posterior Vaginal Wall 196 

90. Large Rectocele in a Multipara 201 

91. Sulcus Tears and Thinning of Perineal Body in a Multipara 202 

92. Showing Support Given by Levator Ani and Triangular Ligaments to Pelvic Viscera 203 



xviii ILLUSTRATIONS 

193. Showing Effect of Sulcus Lacerations of Levator Ani and Triangular Ligaments. . . 203 

194. Complete Laceration of Perineum 204 

195. Prolapse of Uterus; Prolapsed Rectal Mucosa; Fibrolipoma of Thigh 205 

196. Cystocele; Rectocele 206 

197. Normal Xulliparous Outlet, Patient Straining 207 

198. Relaxed Outlet, Patient Straining 207 

199. Relaxed Outlet 208 

200. Emmet Perineorrhaphy; Outline of Denudation 209 

201. Emmet Perineorrhaphy ; Denudation Completed 210 

202. Emmet Perineorrhaphy; Sulcus Sutures Tied on Both Sides 210 

203. Transverse Fascial Split and Introduction of Crown Sutures 211 

204. Diagrammatic Sketches of Emmet Perineorrhaphy 211 

205. Hegar Perineorrhaphy; Lines of Denudation 212 

206. Hegar Perineorrhaphy; Denudation Completed 212 

207. Hegar Perineorrhaphy; Crown Sutures Introduced 213 

208. Hegar Perineorrhaphy; Levator Ani Suture 214 

209. Hegar Perineorrhaphy; Levator Suture in Marked Cases 215 

210. Completion of Subcuticular Suture of Emmet or Hegar Perineorrhaphy 216 

211. Operation for Complete Tear of Perineum 217 

212. Operation for Complete Perineal Tear 217 

213. Suture of Rectovaginal Septum by Linen 217 

214. Diagram Showing Introduction of Sutures in Operation for Complete Tear of 

Perineum 218 

215. Sanger Anterior Colporrhaphy ; Vaginal Wall and L^nderlying Fascia Being Cut Away 218 

216. Sanger Anterior Colporrhaphy; Suture Started at Anterior End of Incision on Vaginal 

Surface 218 

217. Sanger Anterior Colporrhaphy; Suture Carried Through Vaginal Wall 219 

218. Anterior Colporrhaphy or Cystopexy; Outline of Initial Incision 219 

219. Anterior Colporrhaphy or Cystopexy; Separation of Bladder from Anterior Vaginal 

Wall 219 

220. Anterior Colporrhaphy or Cystopexy; Further Separation of Bladder from Uterine 

Wall 219 

221. Anterior Colporrhaphy or Cystopexy; Introduction of Sutures 220 

222. Interposition Operation for Prolapse 221 

223. Interposition Operation 221 

224. Schematic Sagittal Section, Showing Result of Interposition Operation 221 

225. Large Cervical Polyp Projecting from External Os 224 

226. Cervical Polyps, Snowing Origin from Mucous Plicae of Cervix 224 

227. Elongation and Hypertrophy of Cervix 225 

228. Xulliparous Cervix 227 

229. Parous Cervix; ~\\ ell Healed Bilateral Laceration; Mucus in Cervical Canal 227 

230. Parous Cervix; Well Healed Bilateral Laceration 227 

231. Deep Lnilateral Laceration with Irregular Tag of Cervical Tissue 227 

232. Stehate Laceration 227 

233. Deep Bilateral Laceration; Lnequal Division of Cervical Lips; Eversion 228 

234. Deep Bilateral Laceration with Eversion of Lips 228 

235. Nabothian Cysts of Cervix 228 

236. Xulliparous Cervix; Extension of Cervical Mucosa 228 

237. Xulliparous Cervix; Xo Extension; Xo Lacerations. 229 

238. Parous Cervix. Deep Bilateral Laceration 229 

239. Deep Bilateral Laceration; Eversion of Cervical Lips 230 

240. Test Showing Red, Angry-looking Surface is the Cervical Mucosa 231 

241. Deep Bilateral Laceration; Eversion of the Mucosa 231 

242. Trachelorrhaphy ; Repair; Apex of Angle of Laceration Split 232 

243. Trachelorrhaphy; Repair; Cervical Lips Denuded 233 

244. Trachelorrhaphy; Repair; Two Upper Sutures are Tied 233 

245. Trachelectomy ; Cervical Lips Split Laterally 234 

246. Trachelectomy; Cervical Lips Excised 234 

247. Trachelectomy; Sutures Tied 235 

248. Sagittal Section Showing Xormal Anteflexion and Anteversion of L'terus 237 

249. Outline Showing Arc of Imaginary Circle Through Which Fundus Moves 237 

250. Xormal Position of Uterus 238 

251. Retroflexion and Retroversion of Uterus 238 

252. Pathologic Anteflexion; Ill-developed Cervix and Xarrow Canal 238 

253. Retroversion; Slight Flexion; Descensus and Beginning of Prolapse 239 

254. Showing Uterus .in Xormal Position, Ante-position and Retroposition 240 



ILLUSTRATIONS xix 

255. Showing Influence of Shortened Anterior Vaginal Wall 240 

256. Divulsion of Cervix 241 

257. Dudley Operation 242 

258. Pozzi Operation 242 

259-260. Norris Drain in Position 243 

261. Sagittal Section Showing Uterus in Extreme Retroflexion 246 

262. Replacement of Retroflexio-version of Uterus; Cervix Grasped with Tenaculum. . . . 248 

263. Replacement of Retroflexio-version of Uterus; Uterus Straightened Out 248 

264. Replacement of Retroflexio-version of Uterus ; Index Finger in Rectum 249 

265. Replacement of Retroflexio-version of Uterus; Cervix Pushed Back 249 

266. Replacement of Retroflexio-version of Uterus; Tenaculum Has Been Removed 249 

267. Replacement of Retroflexio-version of Uterus; Uterus in Slightly Exaggerated Ante- 

flexion and Anteversion 249 

268. Patient in Knee-chest Position; Vaginal Fornix Packed with Tampons 250 

269. Introducing a Pessary 251 

270. Diagram Snowing Mechanics of Pessary 252 

271. Alexander's Operation 253 

272. Ventrosuspension 254 

273. Coffey's Operation, Steps 1 and 2 255 

274. Coffey's Operation, Steps 3 and 4 255 

275. Webster-Baldy Operation, Steps 1 and 2 256 

276. Webster-Baldy Operation, Step 3 256 

277. Simpson Operation; Skin and Fat Retracted 257 

278. Simpson Operation; Ligament Pulled Up 258 

279. Simpson Operation; Needle Passed Through Fascial Cut 259 

280. Simpson Operation; Round Ligaments Sutured to Under Surface of Fascia 259 

281. Pressure upon Uterus from All Sides Equal 264 

282. Pelvic Floor Torn, Uterus is Now Part of Floor of Pelvis 264 

283. Outline Showing Steps in Development of Procidentia Uteri 265 

284. Prolapse of Uterus; Cervix Presenting at Vaginal Orifice 266 

285. Complete Prolapse of Uterus with Bladder Diverticulum 267 

286. Principle of Support of a Menge Pessary 269 

287. Extraperitoneal Fixation of Fundus, Step 1 270 

288. Extraperitoneal Fixation of Fundus, Step 2 270 

289. Shortening of Uterosacral Ligaments 271 

290. Diagnostic Curettage 280 

291. Chronic Arteriosclerosis or Fibrosis Uteri 281 

292. Diagram Illustrating Vascular Channels of Uterine Wall and Endometrium 282 

293. Section of Wall of Nulliparous Uterus 283 

294. Section of Wall of Muciparous Uterus 283 

295. Group of Arteries from Vascular Layer of Multiparous Uterus 284 

296. Small Artery of Vascular Layer of Multiparous Uterus 285 

297. Large Vein from Vascular Layer of Multiparous Uterus 286 

298. Hydatidiform Mole 290 

299. Multiple Subserous Myomata 293 

300. Longitudinal Sagittal Section of Uterus 294 

301. Uterus Opened, Showing Pedunculated Submucous Myoma 295 

302. Intraligamentous Fibroid 296 

303. Myomatous Uterus Complicated by Inflammatory Lesions of Adnexa 297 

304. Interstitial Myoma Undergoing Necrosis and Cyst Formation 298 

305. Necrosis of Submucous Myoma 298 

306. Necrotic Submucous Myoma Projecting from Cervix 299 

307. Cervical Myoma 300 

308. Multiple Myomata of Posterior Uterine Wall 301 

309. Incarcerated Subserous Myoma 302 

310. Myoma Uteri and Pregnancy 308 

311. Abdominal Myomectomy; Incision Through Capsule of Myoma 314 

312. Abdominal Myomectomy; After Making Incision 315 

313. Abdominal Myomectomy ; After Exposing the Myoma 315 

314. Abdominal Myomectomy; Bed of Myoma Filled up With Catgut Sutures 315 

315. Abdominal Myomectomy; Uterine Incision Closed with Suture of Catgut 315 

316. Supravaginal Hysteromyomectomy with Bilateral Salpingo-oophorectomy 316 

317. Supravaginal Hysteromyomectomy with Bilateral Salpingo-oophorectomy. ....... 317 

318. Supravaginal Hysteromyomectomy with Bilateral Salpingo-oophorectomy 318 

319. Supravaginal Hysteromyomectomy with Bilateral Salpingo-oophorectomy 319 

320. Hysteromyomectomy from Side to Side 320 



xx ILLUSTRATIONS 

321. Supravaginal Hysteromyomectomy with Bilateral Salpingo-Oophorectomy 321 

322. Supravaginal Hysteromyomectomy with Bilateral Salpingo-Oophorectomy 322 

323. Supravaginal Hysteromyomectomy with Bilateral Salpingo-Oophorectomy 323 

324. Supravaginal Hysteromyomectomy with Conservation of Adnexa 324 

325. Supravaginal Hysteromyomectomy with Conservation of Adnexa 325 

326. Supravaginal Hysteromyomectomy with Conservation of Adnexa 325 

327. Diffuse Adenomyoma of Uterus 326 

328. Longitudinal Transverse Section of Uterus 326 

329. Epithelioma of Cervix 331 

330. Early Epithelioma of Cervix 332 

33 1 . Squamous Cell Carcinoma of Vaginal Cervix 332 

332. Showing Predisposition of Epithelioma to Spread by Continuity of Surface 333 

333. Showing Spread of Epithelioma of Cervix, Sagittal and Transverse Sections 334 

334. Showing Spread of Adeno-carcinoma of the Cervix 335 

335. Advanced Epithelioma of the Cervix 336 

336. Histological Section of Finger-like Projection from Cervix 337 

337. Early Carcinoma of the Endometrium 343 

338. Advanced Carcinoma of the Endometrium 344 

339. Chorioepithelioma of the Fundus (in Color) {Frontispiece) 

340. Metastases of Chorioepithelioma in Kidney, Liver, Lung and Pancreas 347 

341. Panhysterectomy for Carcinoma 349 

342. Passing Loop of Catgut about L^reter 350 

343. Ligation of Uterine Vessels 351 

344. Dissection of Bladder and Ureters 352 

345. Application of Clamps to Vaginal Wall 353 

346. Paravaginal Incisions 354 

347. Vaginal Hysterectomy 355 

348. Acute Gonorrhceal Salpingitis, Gross 359 

349. Acute Gonorrhceal Salpingitis 360 

350. Uterus and Appendages in Extensive Pelvic Inflammatory Disease Exposed in 

Incision 361 

351. Uterus and Appendages in Extensive Pelvic Inflammatory Disease; Adhesions 

Divided 362 

352. Pyosalpinx and Ovarian Abscess 363 

353. Tubo-ovarian Abscess 364 

354. Hydrosalpinx 365 

355. Tubo-ovarian Cyst 366 

356. Tuberculous Pyosalpinx, Torsion and Necrosis 369 

357. Interstitial Pregnancy 370 

358. Early Extrauterine Pregnancy, Rupture and Bleeding 371 

359. Extrauterine Pregnancy with Beginning Tubal Abortion 372 

360. Longitudinal Section of Tube Shown in Fig. 359 373 

361. Longitudinal Section of Pregnant Tube 374 

362. Abscess of the Ovary 382 

363. Sagittal Section Showing Displacement of Small Uterus 385 

364. Multilocular Cystadenoma of Ovary 386 

365. Diagram Showing Difference in Effect Upon Cervix 387 

366. Early Parovarian Cyst 390 

367. Parovarian Cyst 391 

368. Diagram Showing Intra- and Extraperitoneal Position of Cysts (in Color) 392 

369. Fibroma of Ovary 392 

370. Papillomatous Cystadenoma of Ovary 394 

371. Dermoid Cyst of Ovary 397 

372. Ovarian Teratoma with Histologic Sketches of Tissue 398 

373. Displacement of Uterus and Stretching of Tube in Pelvic Intraligamentous Tumor. . 400 

374. Corpus Luteum Cyst of Ovary 403 

375. Ovarian Cyst Twisted on Its Pedicle 405 

376. Ovarian Cyst with Torsion of Its Pedicle 406 

377. Diagram illustrating Spread of Gonorrhceal Infection 413 

378. Bilateral Pyosalpinx 417 

379. Resection of the Ovary 418 

380. Salpingostomy 419 

381. Diagram Showing Streptococcus and Staphylococcus Infections 420 

382. Vaginal Incision and Drainage; Posterior Lip of Cervix Held Forward «... 426 

383. Vaginal Incision and Drainage; Abscess Located by Bimanual Palpation 427 

384. Salpingo-oophorectomy; Points of Ligation and Line of Excision 435 



ILLUSTRATIONS xxi 

385. Salpingo-oophorectomy ; Suture of Cornua and Beginning Peritonealization 435 

386. Salpingo-oophorectomy; Suture of Cornua and Completion of Peritonealization. . . . 435 

387. Salpingo-oophorectomy; Posterior Fixation of Round Ligament 436 

388. Salpingo-oophorectomy; Points of Ligation and Lines of Excision 436 

389. Salpingectomy; Suture of Cornua 437 

390. Salpingectomy; Peritonealization 437 

391. Salpingectomy; Peritonealization, First Step 438 

392. Salpingectomy; Peritonealization, Second Step 438 

393. Disinfection of Skene's Tubules 441 

394. Urethral Tampon in Position 444 

395. Saturating Urethral Tampon 444 

396. Self-Retaining or Mushroom Catheter 446 

397. Prolapsed Urethral Alucosa; Outline of Denudation 447 

398. Prolapsed Urethral Mucosa; Denudation Completed 447 

399. Prolapsed Urethral Mucosa; Sutures Introduced 447 

400. Operation for Relaxation of Vesical Xeck of Urethra, First Step 448 

401. Operation for Relaxation of Vesical Xeck of Urethra, Second Step 448 

402. Urethral Caruncle 450 

403. Irrigation of Bladder With Two-way Catheter 455 

404. Vesicovaginal Fistula 463 

405. Urethrovaginal Fistula 463 

406. Vesicocervical Fistula 464 

407. Rectovaginal Fistula 464 

408-409. Uretero vaginal Fistula 464 

410. General Scheme of Operation in Vesicovaginal Fistula 467 

41 1. Tuberculosis of Kidney; Upper Half Diseased 474 

412. Suspension of Kidney by Edebohl's Technic 482 

413. Bloodless Nephrotomy Incision 483 

414. Resection of Last Rib in Nephrectomy 484 

415. Ureteral Anastomosis 492 

416. Uretero-vesical Anastomosis 493 

417. Method of Implanting Ureter into Intestine 494 

418. Method of Implanting Ureter into Intestine 495 

419. Appendicectomy 504 

420. Appendicectomy (Clark's Method) 506 

421. Triangular Shape of Abdominal Cavity on Sagittal Section 507 

422. General Ptosis 508 

423. Midline Ptosis 509 

424. Right-sided Ptosis 510 

425. Exercises for Ptotic Patients; Simple Means of Obtaining Trendelenburg Position. . 511 

426. Exercises for Ptotic Patients; Exaggerated Expansion of Chest 511 

427. Exercises for Ptotic Patients; Leg Flexed Upon Thigh 5 12 

428. Beyea's Operation; Suturing of Gastrohepatic Omentum 5H 

429. Gastropexy ; Coffey's Operation 5 J 5 

430. Diagram Illustrating Beyea's Operation 5 J 5 

431. Scheme of Completed Beyea's and "Hammock" Operation 5 J 6 

432. Suspension of Hepatic Flexure; Reed's Method 5 X 7 

433. Suspension of Sigmoid 5 J 8 

434. Points of Anastomosis and Obstruction in Gastro-intestinal Tract 519 

435. Excision of Fistula in Ano 5 2 6 

436. Removal of Hemorrhoids by Clamp and Cautery 5 2 9 

437. Moschcowitz's Conception of Prolapse of Rectum; Incipient Prolapse (in Color). . . 530 

438. Moschcowitz's Conception of Prolapse of Rectum; Partial Prolapse (in Color). . . . 530 

439. Moschcowitz's Conception of Prolapse of Rectum; Incomplete Prolapse (in Color) . . 531 

440. Moschcowitz's Conception of Prolapse of Rectum; Complete Prolapse (in Color) . . . 531 

441. Scheme for Inserting Sutures in Moschcowitz's Operation 533 

442. Normal Posture 537 

443. Kangaroo Posture 539 

444. Gorilla Posture 539 

445. Slumped Visceroptotic Figure 54° 

446. Overf eminine Figure 540 

447. Patient's Outline Being Traced 541 

448. Corset for Kangaroo Posture 544 

449. Corset for Gorilla Posture 544 

450. Bad Type of Corset. Hour-glass Shape 545 

451 . Good Type of Corset 545 



xxii ILLUSTRATIONS 

452. Storm's Sacroiliac Belt 548 

453. Merrill's Sacroiliac Splint 549 

454. Fat Overhanging Abdomen 551 

455. Smear of Pus from Urethra, Vagina, and Cervix 557 

456. Appearance of Gonococci in Stained Preparation (in Color) 558 

457. Tuberculous Pyosalpinx with Torsion of Ovary and Tube 565 

458. Chancre of Cervix, Engrafted on an Erosion 572 

459. Chancre of Cervix 573 

460. Secondary Ulcer of Posterior Lip of Cervix 573 

461. Schematic Outline of Generative Tract Showing Escape of Ovum, Penetration of 

Spermatic Particles, Fertilization of Egg 598 

462. Semi -diagrammatic Outline of Uterus Showing Various Causes of Sterility 599 

463. Semi- diagrammatic Outline of Uterus Showing Various Causes of Sterility 600 

464. (A) Atrophic Ovary; (B) Thickened Capsule; (C) Abdominal Ostium of Tube. . . . 601 

465. Sterility Produced Through Gonorrhoea Causing Pyosalpinx, Perioophoritis and 

Pelvic Adhesions 602 

466. Abdominal Incisions 624 

467. Battle's Incision: (^4) Skin Incision; (B) Fascial Incision 625 

468. Battle's Incision: (A) Through Semilunar Line; (B) Through Anterior Lamella of 

Rectus; (c) Omentum; (d) Rectus Muscle 626 

469. McBurney's Incision; Skin Incision 627 

470. McBurney's Incision; External Oblique Split 628 

471. McBurney's Incision; Internal Oblique Split 628 

472. McBurney's Incision: (A) External Oblique; (B) Internal Oblique; (C) Peritoneum; 

(D) Appendix 629 

473. Prone Position for Kidney Operations 629 

474. Kelly's Incision 630 

475. Mayo's Incision 630 

476. Muscles of Lumbar Area, Showing Outline of Edebohl's Incision and Mayo's Incision 631 

477. Israel's Incision 632 

478. Robson's Incision 632 

479. Towelling the Incision, One Side Completed 633 

480. Towelling the Incision, Both Sides Completed 634 

481. Incision Made, Sides Protected with Gauze Pads, Self -retaining Retractor in Position 634 

482. Separation of Muscle Fibers 635 

483. Opening the Peritoneum 635 

484. Separation of Rectus Muscle from Its Lateral Attachments 636 

485. Lengthening the Incision 636 

486. Eversion of Peritoneum with Closing Suture; First Method 637 

487. Trendelenburg (Elevated Pelvis) Position 638 

488. Elliott Position (Elevated Thorax) for Upper Abdominal Operations 638 

489. Eversion of Peritoneum; Closing Suture; Second Method 644 

490. Closing Fascia, Showing Detail of Suture for Overlapping 645 

491. Finish of Buttonhole Stitch 646 

492. Suprapubic Pelvic Drain 647 

493. Abdominal Dressing Applied 648 

494. Enteroclysis Apparatus with Visible Drip 666 

495. Visible Drip Glass Connecting Tube 666 

496. Bed with Head Elevated 667 

497. Fowler Bed 668 

498. Portable Heat Cabinet 673 

499. Short-circuiting for Intestinal Obstruction, Ileo-sigmoidostomy 683 

500. Short-circuiting for Intestinal Obstruction, Ileo-colostomy 683 

501. Abdominal Binder for Post-operative Use 697 

502. Bivalve and Sims' Specula Introduced — Patient in Dorsal and Sims' Position — 

Exposure of Cervix and Vaginal Vault 699 

503. Smith Pessary — Used in Treatment of Retroversion 701 

504. Hodge Pessary — Used When Vaginal Vault is Shallow 701 

505. Soft-rubber Ring Pessary; Useful in Elderly Women with Narrow Vaginal Orifice. . 702 

506. Disk Pessary; Useful in Elderly Women with Descensus and Marked Cystocele. . . . 702 

507. Menge Pessary (Assembled) ; Useful in Prolapsus in Elderly Women 703 

508. Menge Pessary (with Stem Detached) 703 

509. Intrauterine Douche Nozzle 704 

510. Vaginal Vault Packed with Tampons 704 

511. Uterine Pack 705 

512. Vaginal Pack with Suprapubic Pressure 705 



ILLUSTRATIONS xxiii 

513. Vaginal Douche Nozzle of Glass 706 

514. Sketch of Correct Position for Douche 706 

515. Vaginal Tampon 707 

516. Filling Vaginal Tampon 708 

517. Good Type of Corset 709 

518. Exercises for the Nervous Woman — First Exercise 710 

519. Exercises for the Nervous Woman — Second Exercise 710 

520. Exercises for the Nervous Woman — Third Exercise 710 

521. Exercises for the Nervous Woman — Fourth Exercise 710 

522. Exercises for the Nervous Woman — Fifth Exercise 710 

523. Exercises for the Nervous Woman — Sixth Exercise 710 

524. Exercises for the Nervous Woman — Seventh Exercise 710 

525. Exercises for the Nervous Woman — Eighth Exercise 710 

526. Means of applying Radium in Gynecological Diseases — Needles Containing Radium ; 

Radium Enclosed in Platinum Capsules 716 



INTRODUCTION 

Medical text-books vary greatly in literary style and construction : thus, 
one embodies the complete individuality of the author, as exemplified by his 
daily clinical work, but scant reference being made to the literature con- 
tributing to his subject; another otters a digest of a vast bibliography, more 
or less well selected, depending on the competency of the author to act as a 
judge, and endeavors to feature the cardinal points that he considers worthy 
of imitation. Such text-books, however., evidence, on the one hand, a lack 
of judicial balance, and. on the other, an absence of a well-defined hall-mark 
stamped by the writer's own experience. Still a third author, as repre- 
sented by Doctor Anspach. selects his literary references with great care 
and. combining these with the observations gathered from his matured ex- 
perience, he constructs a well-balanced text-book. 

In Doctor Anspach's treatise on Gynecology ample reference is made to 
epoch-making and constructive contributions, but his text is so well arranged 
as to make it devoid of encyclopaedic dulness. Painstaking care has been 
devoted to the elucidation of all the basic factors in embryology, anatomy, 
and physiology, variations from which mark abnormal morphology, and 
morbid physical changes that lead to the many functional disturbances ob- 
served in gynecologic practice. 

It is a common observation among teachers in our medical schools that 
students well drilled in the cardinal branches of the first two years, all too 
frequently approach the clinical problems of the last two years so deficient 
in this fundamental knowledge as to make its translation into practical 
medicine of little or no value. To bridge this hiatus between the scientific 
and the clinical domain Doctor Anspach has drawn from the newest, as well 
as from the classic, sources of information, the specialized and general facts 
that will freshen up and adapt the student's mind for the fullest comprehen- 
sion of gynecologic problems. 

From the chapters on Embryology. Developmental Anomalies. Anatomy, 
and Physiology the reader is carried logically forward into the intricacies of 
anamnesis, physical examination, and laboratory investigations, these chap- 
ters being so closely correlated as to develop the deductive powers of the 
student, making of him a well-poised diagnostician, rather than the slave of 
a memorized symptomatology that, when the atypical case is encountered, 
inevitably leads him into a quagmire of doubt. 

When the chapters on the practice of gynecology are reached, all the 
capital procedures that have found a stable setting in practice are consid- 
ered, and usually more than one method is ottered for the reader's selection. 

A most instructive chapter is that devoted to the hygiene and proper care of 
adolescent girls, a subject that, because of its ultimate influence upon the 
welfare of the adult woman, is of far-reaching importance. All too fre- 
quently of late gynecologic text-books are so crammed with surgical thera- 

XXV 



xxvi INTRODUCTION 

peutics as largely to exclude prophylactic measures and immediate medical 
and hygienic treatment of conditions that, if not cured in the early stages, 
will certainly attain surgical proportions. 

In this book the general practitioner will find a wealth of suggestions as 
to office and bedside treatment of gynecologic patients. Special considera- 
tion is given to the endocrine system in its relation to the functional aberra- 
tions of women. Our knowledge of this abstruse subject is at best more 
or less inchoate,, but that which is required by the gynecologist has been 
clearly set forth. 

In such special complaints as local skin affections and backache, Doctor 
Anspach has called to his aid the services of skilled specialists, who give to 
these subjects a breadth of view that is not to be found in the usual text- 
books on gynecology. Here, for the first time, the therapeutic value of 
radium and the Rontgen ray has received adequate consideration. Full 
working instructions as to the choice of cases and the application of these 
remedies in the treatment of carcinoma and myoma of the uterus and myo- 
pathic hemorrhages are given. That able rontgenologist. Dr. Henry 
Pancoast. has brought this portion of Doctor Anspach's book well abreast 
of the times. 

To attempt to draw attention to all the excellent features of this text- 
book would encompass more space than has been allotted to the introduc- 
tory matter. Suffice it to say that the work is most comprehensive, and 
deals in a highly instructive way not only with diseases of women, but also 
with those coincident renal and abdominal lesions that are frequently en- 
countered in the course of gynecologic affections. 

In concluding this introductory note I take pleasure in extending a cor- 
dial commendation to a book that has had the well-balanced authorship of a 
specialist who has devoted a number of years to faithful work as an inves- 
tigator and as a teacher, and to the practice of gynecology and abdominal 
surgery in their broadest and best sense. 

John G. Clark. 
Philadelphia, 

Jan. 21, 1921. 



GYNECOLOGY 

CHAPTER I 
EMBRYOLOGY 

EMBRYOLOGIC STRUCTURES 

The Wolffian Body and the Wolffian Duct.— The Wolffian body and the 
Wolffian duct are the first structures to appear in the development of the 
genito-urinary system in man. Each Wolffian body is made up of a series 
of tubules terminating at one extremity in a convoluted vascular tuft form- 
ing a glomerulus, and at the other emptying into the Wolffian duct (Fig. 
i, a). Each tubule comprises a glomerulus and a secreting and a collecting 
area (Fig. 2). The Wolffian body is a functionating excretory organ — the 
primitive' kidney — that attains full development at about the end of the 
second month (Fig. 3). Its excretion is discharged into the Wolffian duct, 
which runs toward the tail of the embryo and empties into the cloaca or 
dilated terminal segment of the large gut. Almost as soon as it is fully 
formed the Wolffian body begins to atrophy, its function being gradually 
assumed by the true kidney, which has developed in the meantime. 

The Miillerian Duct. — The Miillerian duct develops at the side of, and 
is closely related to, the Wolffian duct (Fig. 1, b). The lower parts of 
both ducts on each side converge toward those of the opposite side. From 
the point at which they meet the ducts run toward the cloaca, forming the 
urogenital strand, the Miillerian ducts running in the median line and the 
Wolffian ducts to the outer side (Fig. 4). 

The Sexual Gland, — At about the time the Miillerian duct is formed, the 
cells on the median surface of the Wolffian body become aggregated, form- 
ing what is known as the sexual gland (Fig. i, c). In the female this aggre- 
gation ultimately develops into the ovary, some of the original cells, distin- 
guished by their large size, clear protoplasm, and conspicuous nucleus, con- 
stituting the primary germ cells or the primordial ova (Fig. 5), the remaining 
cells forming the germinal epithelium. 

FCETAL STRUCTURES 

The Ovary. — The cells of the sexual gland receive vascular connective 
tissue from the Wolffian body, separating them into large islands or strands 
in which the primitive ova are surrounded by the germinal epithelium. The 
larger islands are divided into smaller ones, until ultimately groups are 
formed that consist of one primordial ovum surrounded by a ring of ger- 
minal epithelium, constituting the primordial follicles of the ovary. These 
follicles are embedded in a vascular connective-tissue stroma that, at the 
periphery of the organ, is condensed and forms a capsule that, from its 
white appearance, is known as the tunica albuginea (Fig. 5). 

1 



GYNECOLOGY 




MM 



^ 



The Uterus. — The apposed surfaces of the Miillerian ducts — one from 
each side — become fused at about the eighth week. The septum disappears, 

and the two tubes become converted into 
a single larger tube that forms the uterus 
(Fig. i,d). 

The Fallopian Tubes. — Above the point 
where they fuse to form the uterus, the 
Miillerian ducts remain separated and be- 
come the Fallopian tubes. 

The Vagina. — The vagina is derived 
from the lower extremities of the fused 
Miillerian ducts. For a time this portion of 
the duct is solid, but at about the fourth 
month it becomes hollowed out and com- 
municates with the cloaca (Fig. i, e and 
Fig. 6). 

The External Genitalia. — The enlarged 
terminal segment of the hind-gut known as 
the cloaca is closed externally by a mem- 
brane, becoming divided into two sections 
by the projection of the perineal ridge (Fig. 
7). The anterior section is known as the 
urogenital sinus. At about the fifth week a 
rounded projection, the genital tubercle, is 
formed in front. Upon its under surface it 
is divided by a groove ; after rupture of the 
cloacal membrane the edges of this groove 
form the labia majora, labia minora, and 
the clitoris. The opening into the urogeni- 
tal sinus between the labia becomes the 
vulvar cleft, and the sinus itself is now the 
vestibule. The vagina communicates with 
the urogenital sinus by an aperture that 
later becomes the vaginal orifice. It is 
guarded by annular folds which subse- 
quently become the hymen. The posterior 
part of the cloacal space is the gut section, 
and between it and the urogenital section a 
wedge of tissue becomes the perineal body 
(Figs. 8-12). 

The Bladder and Urethra. — The an- 
terior part of the urogenital section of the 
cloaca is designated as the allantoic space ; 
the primitive ureters empty into it pos- 
part of the allantoic space becomes expanded and 
summit of the bladder, while the lower part, into 




Fig. I. — Schematic outline showing the de- 
velopment of the reproductive organs: (A) 
showing the Wolffian tubules, with glomeruli 
at the distal ends, entering the Wolffian duct; 
(B) the Miillerian duct developing parallel 
with, and to the mesial aspect of the Wolffian 
duct; _(C) fusion of the Miillerian ducts of 
both sides to form the primitive uterovaginal 
canal and the Fallopian tubes; development of 
the genital gland below the Wolffian tubules; 
(D) atrophy of the Wolffian tubules and dis- 
appearance of the glomeruli, further develop- 
ment of the genital gland, beginning formation 
of fimbria at the abdominal ostium of tube, 
development of the uterine cavity and the dif- 
ferentiation of it from the vaginal canal; (£) 
atrophic remains of the Wolffian structures, 
the genital gland has become the ovary, the 
free end of the Miillerian duct is represented 
by the fully developed Fallopian tube; the 
fused portion is represented by the uterus and 
the vagina. 



teriorly. The upper 
forms the body and 
which the ureters open, forms the vesical trigone and urethra (Fig. 7). 

The Rectum. — The posterior section of the cloaca forms the rudimentary 



EMBRYOLOGY 



Wolffian duct — 



A developin 
branc 




Mesoderm 



Glomerulus 



Epithelial layer 



Epithelial layer 



Fig. 2. — Enlarged schematic Wolffian tubule at the height of its develop- 
ment, from an embryo 10 mm. long. (Kollmann.) 



Plica phrenico- 
mesonephrica 



Sexual gland 



Wolffian body! 



Mesentery of 
gland 

Wolffian duct 



Sexual 
gland 



Genito 
ligamen 

Plica inguino--^- 
mesonephrica l 




inguinal ■ \ ■ 

ient \ -"^fr 

inp-uino- — " 



Ligament of gland 

Umbilical arteries 



Allantoic duct 
l T mbilical vein 



Fig. 3. — The Wolffian bodies and the sexual glands of a human embryo of about 
six weeks. (Piersol.) 

rectum. Towards this an invagination of the ectoderm is projected from 
the surface. The two finally meet, and fuse by the absorption of the inter- 
vening tissues ; the point of fusion marks the line of division between the 
anus and the rectum (Fig. 7). 

The Ureter and Kidney. — The ureter has its origin in a bud-like expan- 



GYNECOLOGY 



Abdominal ostium 



Tube, tubal part of 
Mullerian duct 



Urinary bladder 



Wolffian duct 




Uterine part of 
Mullerian duct 



Vaginal part of 
Mullerian ducts 



Uro-genital sinus. 



Fig. 4. — Showing a schematic solid reconstruction of the reproductive organs, especially the urogenital strand, 

from fetus 29 mm. long. (Kollmann.) 



i* 



Germinal epithelium 

«lffe 






- mw^:^f^~- 






'C^C: ! 










Ova 



HI f^MSfe 



^m»>«ssa 



-, ^ 



. Ovarian 
stroma 



Fig. 5. — -Developing ovary of embryo; germ cells being broken up 
by stroma and vascular tissue. (Piersol.) 



EMBRYOLOGY 5 

sion from the lower end of the Wolffian duct, near the cloaca. It grows 
upward, behind the Wolffian body, and here its upper extremity dilates and 



Dorsal 



Ventral 



Cerv 



Portio vaginal 




Vaginj 



Proctodeum 



Ectoderm 




FlG. 6. — Development of the cervix and the vagina. Median 
longitudinal section of the utero-vaginal canal at the level of the 
portio vaginalis uteri of an embryo 260 mm. long. The portio 
vaginalis is beginning to be defined and the supravaginal circular 
muscle is developing. The lumen extends to its lower end, which 
is closed by an epithelial plug. The vagina is still altogether 
solid, its future lumen is indicated by the solid epithelial cord 
that traverses it. From this cord there grows into the surround- 
ing mesenchyme, forward and backward at different levels, two 
solid projections of epithelium, the anlagen of the anterior and 
posterior fornices. (Keibel and Mall.) 




Ovary 



Ccelom 

Urinary bladder- 
Clitoris and vestibule 

Symphysis 
Anus 



Wolffian duct 



Rectui 



Spinal medulla 



Spinal cord 



Fig. 7. — A and B: (A) sketch of a model exhibiting the formation of the bladder, ureters, external genitalia 
and anus, from a fetus 29 mm. long x 60; (B) detail of "A" showing formation. (Kollmann.) 



subdivides, forming the renal pelvis and calyces, and finally also the collect- 
ing tubules. The remainder of the kidney is developed from a surrounding 



6 GYNECOLOGY 

area of tissue termed the renal blastema, the tubules of which subsequently 
unite with those growing from the renal pelvis. 

THE GENERATIVE ORGANS AT BIRTH AND DURING CHILDHOOD 

At birth the female generative organs have not attained their full devel- 
opment. This process goes on slowly during childhood, and is most marked 
in the years just preceding the establishment of the menstrual function. 

„ ,* Umbilical cord 




Lower extremity 



'% 



V 



Coccygeal tubercle 

Fig. 8. — External genitalia of an embryo 18 mm. long. 
Between the umbilicus and the coccygeal tubercle is 
the cloacal tubercle; on its anal slope are the ostium 
urogenitale and the anal groove. (Keibel and Mall.) 




-Glans 
— ^Genital folds 

y — Labio-scrotal 
folds 

-Opening of 
urogenital sinus 

Anal groove 
' Coccygeal eminence 

Fig. q. — Indifferent stage of external genitals of 
embryo of thirty-three days. X8. (Keibel.) 



—Glans clitoridis 

Labium majus 
Nympha 
Urogenital sinus 

Anus 
Coccygeal eminence 



Fig. 10. — External genitalia of the female, 
embryo of nine weeks. (Keibel.) 






Glans clitoridis 

I Prepuce 

Urethra 
— Nympha 
W- Vaginal orifice 



Fig. 11.— External genitalia of the female, 
embryo of eleven weeks. (Kollmann.) 



Fig. 12. — External genitalia of the female, 
embryo of sixteen weeks. (Kollmann.) 



The Ovary. — At birth the ovary is long and narrow, somewhat resem- 
bling, on triangular cross-section, a dog's ear. In the earliest days it lies 
above the true pelvis, but during the first two years of life it drops below 
the pelvic brim. It grows slowly and attains its full development at 



EMBRYOLOGY 



Capillary system / ; ' 
in cortex^ 



Follicles 




Arteriae ovaricae 
'propria? 



Veins' " 



Fig. 13. — Ovary of new-born child. Vessels injected with lamp-black 
gelatine. (Clark.) 



u ter Ift e t 




^f.mb.MTt 



Fig. 14. — Ovary of new-born child showing the gross relationship of the ovarian artery to the ovary and 

tube and to the uterus. (Clark.) 



puberty. The maturation of primordial follicles goes on from earliest life, 
the follicles not rupturing, but undergoing atresia, until, by the deposit of 
connective tissue in the medullary portion and the penetration of the blood- 



8 



GYNECOLOGY 



vessels to the cortical areas, the follicles then begin to undergo develop- 
ment (Figs. 13-19). 

The Uterus. — At birth the cervix is disproportionately large, making up 
more than one-half of the organ. Its wall is much thicker and better devel- 
oped than the fundus. The fundus is less rounded than in the mature uterus, 
and the uterine angles merge directly with the tubes, suggesting previous 
fusion of the Miillerian ducts. The mucosa of the cervix, with its arbor- 
vitse-like arrangement, extends up into the fundus. The position of the uterus 



Follicular wreaths 



Follicular wreath - 



Follicular wreath - 



Arteriae ovaricae .- 
propria?' 




Follicular wreath 



* Veins 



Artery/ 



Fig. 15. 



-Ovary of a child two \-ears old. The vessels have become more tortuous, and numerous follicles lying- 
next to the parallel arteries are in the process of evolution. (Clark.) 



is high, the fundus being opposite the fifth lumbar vertebra. During child- 
hood the organ descends into the pelvis, the cervix and body assume mature 
proportions, the fundus becomes arched, and the mucosa of the cervix be- 
comes sharply differentiated from that of the fundus (Fig. 20). 

The Fallopian Tube. — At birth the Fallopian tubes are long, twisted, tor- 
tuous, and the fimbriated extremities are poorly developed. During child- 
hood they grow shorter, many of the convolutions disappear, and the fimbri- 
ated extremities attain their full development. 

The Vagina. — At birth the vagina is long and narrow ; its walls are 



EMBRYOLOGY 



thick, and the rugae extend to the vaginal vault. As the uterus descends it 
diminishes in length, the fornices widen, and the rugae in the upper 
portion disappear. 

EMBRYONIC RESTS AND THE NEW 
FORMATIONS ORIGINATING IN 

THEM 

In the generative organs of the 
adult female there are seen rests 
or remnants of certain embryonal 
structures that served their pur- 
pose in early fetal life, but later, 
after the embryo had been fully 
formed, became functionless and 
underwent atrophy. These fetal 
remnants are represented in the 
Wolffian tubules and the Wolffian 
duct (Fig. i, e). 

Embryonic rests are found 
principally in certain localities, 
as, for example, in the broad liga- 
ment between the tube and the 
ovary, in the ovarian hilus, at the 
cornua of the uterus, at the sides 
of the uterus and cervix, at the 
lower pole of the kidney, in the 
vault of the vagina or in the 
anterior vaginal wall as far for- 
ward as the external urinary 
meatus, in the rectal wall, and in 
the round ligament. 

The most conspicuous rem- 
nant of the Wolffian body and 
duct is the parovarium, a struc- 
ture embedded between the layers 
of that part of the broad liga- 
ment known as the mesosalpinx. 
It consists of a series of atrophic 
tubules, a long longitudinal and 

numerOUS Vertical Ones, reseill- Fig. 16.— Ovary of a girl rine years old. 
Klinrr +V>^ Ko^V nnr l +cmi-U ^-f tuosity of vessels and progressive enlargement and oblitera- 
ting tne DaCK ana leetn OI t i n of follicles toward periphery, d, d', vascular loops 
a COmb The lonp'itnrlimi wn i cn have surrounded follicles undergoing obliteration. 

tubule of the parovarium, 

known as Gartner's duct, is a remnant of the Wolffian duct; it is dis- 
cernible almost to the cornua of the uterus. Rests may also be found 
microscopically along the sides of the uterus, cervix, and in the lateral 
vaginal walls. From the outer extremity of Gartner's duct there occasion- 




increase in tor- 



10 



GYNECOLOGY 
d d 




Fig. 17. — Ovary of a girl sixteen years old: (a) (a') arteria? parallels ovarii; (b) typical organizing corpus 
luteum; (c), (c') t (c") different stages in the maturation of the follicle; {d), (d') stages in the obliteration of the 
follicle which has not ruptured ; (e) complete retrogression, the central vessels of the hyaline body having almost 

completely disappeared. (Clark.) 

ally develops a small, pedunculated cyst known as the stalked hydatid of 
Morgagni. From the lower extremity of the duct are derived a certain type 
of adenomyoma of the cervix and the majority of vaginal cysts. 



O- re - P - 



■»|gp 



s » 



i*3 >? 

TO O 









J o 2. 
»•" re re c p to 

Wwft 

llliiil 

n " ' 3 S ,."^ H* 

rt-TJ 5 c o g « o 



o'5° 

3 re 3 j^.— <a-S o 
to c 5 £•«" o-^ 

?. 3 TO »W S o"° 



' w <t> 



;re 9 



».. rroq 3 .g.^ 
To n- re re ^p (-< 

o 3<<t>>o 3'~ 3 ' 

p 3 ■ - 




5*o 



P re 

'1/1 Cfi 

Z. p £ g < p H" 

O •-. o c t/> i re 




EMBRYOLOGY 



11 



The outer vertical tubules of the parovarium, known as Kobelt's tubes, 
give rise to small cysts about the size of grapes. The other tubules are the 



Hyaline changes in corpus fibrosum 



Hyaline changes in 3 - '"-^^^^^^^ o< s jy^^JJ^rus. ■ 

corpus fibrosum -•^1-^^^^jj^-^^ "^^^^ jjsyi v\\-^ J A 



Hyaline changes in _ j 
corpus fibrosum* "S 



Cortex deficient in 

blood-vessels- - 



Surface scars- 




Hyaline changes in 
corpus fibrosum 

Site of rupture of 
follicle 



Compressed vessels 
S.-~fV--.,at their entrance 
V 5 * as\ to stroma 



Vein/.... 

Artery, 
Fig. 19. — Ovary of a woman forty-two years old. Death occurred shortly after the menopause. (Clark.) 



seat of well-known intraligamentous parovarian cystomata, which some- 
times reach very large proportions. 

Other remnants of the Wolffian tubules may be found between the 



12 



GYNECOLOGY 



layers of the broad ligament, as well as in the hilus of the ovary itself. 
From these develop the true glandular cystomata of the ovary, the most 
common variety of ovarian cyst (Fig. 21). 

Some authorities assert that embryonal rests of the Wolffian tubules at 
the lower pole of the kidney, in the broad ligament, at the uterine cornua, 
and in the round ligament, may give rise to adenomyomata in these situa- 
tions. Others have shown that most of the adenomyomata that develop in 
the uterus are derived from the Miillerian ducts in the process of evolution 
of the uterine body and endometrium. Oscar Frankl has observed in the 




ski 




Fig. 20. — Contents of the pelvis in an embryo of thr^e and one-half months (X4): 
abdominal wall pulled downward; (A) appendix; (/) ileum; (U) ureter; (O.A.) 
ovarian artery (S.Fl.) sigmoid flexure; (0) ovary; (Ut.) bicornuate uterus; (23) 

bladder 



broad ligaments cornified nodes of epithelium derived from the Wolffian 
bodies. From these rests epidermoid cysts may spring. 

In the early stage of development aberrant cells from the ovum (mul- 
berry mass) may become detached from the other cells and subsequently 
become embedded in any part of the body. They are especially prone to be 
found as rests in the genito-urinary system, since this forms so large a por- 
tion of the early embryo. These aberrant cells may subsequently develop 
and give rise to tumors containing derivatives from any or all the layers of 
the blastoderm. The most common of these growths are the so-called 
dermoid cysts of the ovary (see Chapter XX). 



EMBRYOLOGY 



13 



Rests of suprarenal tissue may be found in the inguinal canal, the round 
ligament, and the fundus of the uterus. Their presence is due to the close 
proximity of the adrenal glands to the sexual organs during the period of 
development. From such embryologic remains hypernephromata may develop. 



\Ve 



^cvcovj axwxiri 




EMBRYONAL RESTS— THE PAROVARIUM, 
consists of two rudimentary organs; 

istTHE EPOOPHORON {THE ORGAN OF ROSENMULLER) 

{equivalent to the epididymus in the male) consists of a number of epi- 
thelial lined tubes i; remains of tubules of the Wolffian body, ascending 
from the ovary and ending in the Wolffian {Gartners) duct 2-2; remains 
of tubules 3-3 sometimes forming hydatids; terminal bulb 4 hydatid cyst 
of Morgagnii: 

2d THE PAROOPHORON 5 {EQUIVALENT TO THE PARADIDYMUS 
IN THE MALE); = 
6-J epithelial lined remnants, others are occasionally found in body of 
uterus, cervix and vaginal wall, and are sometimes the seat of cysts; 8-8-8 
atrophied remains of Wolffian {Gartner's) duct. 

[From standard authors and specimens in Doctor Clark's collection.] 

Fig. 21. — Fallopian tube and ovary, showing mesosalpinx and embryonal rests therein. Schematic view o f 

structures in the broad ligament. 



BIBLIOGRAPHY 

Clark, J. G. : " Histogenesis of Glandular Cysts of the Ovary." Tr. Am. Gyn. Soc., 1903, 

xxviii, 312-322. 
Cullen, T. S. : Adenomyoma of the Uterus. Saunders, Phila., 1908. 
Ellis, E. G., with Keen, W. W., and Pfahler, G. E. : " On Hypernephroma." Am. 

Med., 1904, viii, 1039. 
Frankl, Oscar: " Pathologische Anatomie und Histologic der Weiblichen Genitalorgane," 

in Liepmann's Handbuch der Frauenheilkunde. Band ii, Vogel, Leipzig, 1914. 



14 GYNECOLOGY 

Keibel, Franz, and Mall, E. P. : Manual of Human Embryology. Lippincott, Phila.. 1910. 
Kollmaxx, J. : Handatlas der Entwickelungsgeschichte des Menschen. Fischer. Jena, 1907. 
Kollmaxx : Lehrbuch der Entwickelungsgeschichte. Fischer, Jena, 1898. 
Pick, L. : " 1st das Yorhandensein der Adenomyome des Epioophoron erweisen." Centralbl. 

f. Gynak.. 1900. xxiv, 389-397. 
Piersol, G. A. : Human Anatomy. Lippincott. Phila.. 1907. 
Recklixghausex vox. F. D. : Die Adenomyome und Cystadenome der Uterus — und 

Tubenwandung. Im Anhang : Klinische Xotizen zu den volumosen Adenomyome 

des Uterus. Freund, Berlin. 1896. 
Thumim, L. : " Ueber die adenomatose Flyperplasie am cervicalen Drusenanhang des 

Gartner'schen Ganges. (Nebst Mittheilung eines einschlagigen Falles.") Archiv 

f. Gynak.. 1900, lxi. 15-36. 
Tuttle. J. P. : Diseases of the Anus, Rectum and Pelvic Colon. Appleton. X. Y., 1907. 



CHAPTER II 

THE DEVELOPMENTAL ANOMALIES OF THE GENERATIVE 

ORGANS 



The Ovary. — Complete absence of both ovaries is seen only in mon- 
strosities. The absence of one ovary is quite unusual, but has been found 
associated with defect of one Miillerian duct. The kidney of the same side 
may be absent. Rudimentary or poorly-developed ovaries often co-exist 
with the various malformations of the uterus. Rudimentary ovaries are 
usually small, but may be almost normal in size. They contain few, if any, 
primordial follicles. So-called supernumerary ovaries are merely portions 
of the ovaries snared off by peritoneal bands or adhesions, or small fibro- 
myomata of the ovary in the broad ligament. 




Fig. 22. — Uterus unicornis. 



Fig. 23. 



-Uterus didelphys (uterus duplex separatus; 
vagina duplex separatus). 



The Fallopian Tubes. — Complete absence of both tubes occurs only in 
monstrosities. The absence or partial development of one tube is coinci- 
dent with a similar condition of the corresponding uterine horn. The con- 
voluted fetal type may persist, even in the adult. Supernumerary or double 
tubes are very rare. Accessory tubes and accessory abdominal ostia are not 
infrequent. Diverticula from the mucosa into the wall of the tube are common. 

The Uterus. — It is only necessary to bear in mind the successive steps 
in the development of the uterus in order to understand the various malfor- 
mations that may arise. The Miillerian ducts at first are solid strands 
throughout their entire length, with the exception of the upper extremity, 
which is hollowed out. Later on these strands become possessed of lumina, 
and join one another at the site of the future cervix. Union of the two 
above the cervix, as far as the fundus follows, and the intervening and approxi- 
mated septa then disappear, although atrophy of the septa is not so rapid as 
outside fusion. At first the uterus so formed is somewhat flattened on top, 
but at the end of intrauterine life the fundus has developed, forming the 

15 






16 



GYNECOLOGY 

which is succeeded by 



the infantile and then by 



foetal type of uterus, 
the virginal type. 

Complete failure of both Miillerian ducts to develop is found only in mon- 
strosities. Many reported cases of complete failure were really cases of 
rudimentary development. Complete defection of one Miillerian duct (uterus 
unicornis) (Fig. 22) is usually associated with an absence of the correspond- 
ing ovary, kidney, and ureter, and occurs in non-viable feti, many of the 




FlG. 24. — Uterus pseudodidelphys (uterus bicornis 
septus, vagina septa). 



Fig. 25. — -Uterus duplex bicornis. 



cases described in adults being really instances of high-grade uterus bicor- 
nis septus with vagina septa, one side being rudimentary to an 
extreme degree (Figs. 22, 24 and 29). 

The two Miillerian horns may unite at the cervix, the septa between 
them remaining intact, and no fusion of the two sides above the cervix taking 
place, thus forming the uterus duplex bicornis (Fig. 25). This abnormality 
is found in well-developed adult females, and, together with the bicornate 




Fig. 26. — Uterus duplex septus. 



FlG. 27. — Uterus duplex subseptus. 



uterus, constitutes the most frequent form of uterine anomalies. As a rule, 
two vaginal canals surrounded by a common sheath exist, their orifices 
being guarded by a common hymen. The vaginal septum may extend either the 
entire distance from the cervix to the introitus or only part of the way. The 
two uterine horns are seldom equally well developed. In these cases men- 
struation and pregnancy may take place normally. Hsematometra may arise 
in the less well-developed side, and this may also tend to obstruct labor. 

The Miillerian ducts may develop and fuse from the cervix to a point 



DEVELOPMENTAL ANOMALIES 



17 



near the fundus, the intervening septum as far as the external os persisting. 
In this way is formed the uterus duplex septus (Fig. 26) ; the vagina may 
be double or single. The septum may not extend to the external os, and when 
this occurs the condition is known as uterus duplex subseptus (Fig. 27). As 
a rule, menstruation is normal, and pregnancy and labor may occur in either 
or in both sides at the one time. 

When the Miillerian ducts unite at the position of the cervix to the full 
normal extent, the intervening cervical septum having disappeared, but 
fail to fuse above this point, the condition is termed uterus bieornis (Fig. 28). 
One horn may be smaller than the other (Fig. 29), or may be imperforate, 
although furnished with a functionating endometrial cavity. The under- 
development of one side may be so marked that the condition will resemble 
the uterus unicornis. In the latter case the undeveloped half of the uterus 
is represented merely by a thin, band-like or rounded cord, having no 
cavity, and joining the fully-developed horn at about the site of the internal 
os. Occasionally in these cases the ovary is present, and the tubes are 
recognizable as connective-tissue strands having more or less well-developed 
fimbriae. In some cases neither the tube nor the ovarv can be found. 




Fig. 28. — Uterus bicoinis. 



Fig. 20. — Uterus bieornis, with dwarfing 
of one horn. 



A form of maldevelopment marked by congenital dwarfing of the entire 
uterovaginal tract, affects most often the uterus bieornis. At the site of the 
uterus in these cases there is seen a flattened or rounded body, from one to 
three centimetres long, the upper extremity of which is continued on both 
sides in the form of strands. The cervix and the lower part of the uterine 
horns may be relatively well developed. The ovaries are always present, 
but are usually of small size. The tubal fimbriae not infrequently are well 
formed. The mons pubis and the labia majora contain little fat. The labia 
minora are frequently well developed. The clitoris may be hypertrophied 
and hypospadias may be present, the parts presenting the appearance of a 
malformed male. The vagina is usually obliterated entirely. 

The uterus may show a persistence of the fetal type — the uterus fcetalis. 
It is considerably shorter than the normal adult form, cylindric in configura- 
tion, the fundus being flattened. The cervix is often as long as the body, 
and the small corpus is very sharply anteflexed upon it. The walls of every 
part are thin, but the cervii- is better developed than the fundus. The vaginal 
cervix is less prominent than the normal, and projects but slightly into the 
vagina. The external os takes the form of a round pit or a fine transverse 
2 



18 



GYNECOLOGY 



slit. The uterine cavity is always present, and the ovaries are of the in- 
fantile type. The tubes are fetal in form, and are supplied with fimbriae. 
The vagina is usually abnormally short and narrow, although it may be 
normal. The mons pubis and the labia majora are not prominent, but the 
clitoris and especially the labia minora are well developed. 

The uterus may be relatively smaller than the normal virginal type. 
It is usually known as uterus infantilis, or congenital smallness of the uterus, 
the condition being the result either of defect at birth or of serious consti- 
tutional illness in the earlier years of life which arrested the growth of 
the organ. 

Certain congenital malpositions of the uterus occur, such as latero- 
position, when the uterus is drawn either toward the right or toward the left 

wall of the pelvis ; or the organ 
Xtf 33&<z-k&jr t may occupy an oblique posi- 

tion, so that the vaginal cervix 
is directed or curved to one side, 
whereas the body is directed 
or bent toward the other side. 
These conditions must be at- 
tributed to unequal develop- 
ment of the ligaments. The 
most frequent deviations that 
are met with in young women 
are due to malposition, the re- 
sult of failure of a proper bal- 
ance or tension in the ligamen- 
tary suspension of the uterus in 
the pelvis. Retroversion and 
retroflexion of the uterus are fre- 
quently found in the foetus and 
in the new-born infant, and con- 
genital prolapse associated 
with spina bifida has been de- 
scribed. The uterus may also 
at birth be the seat of a sharp anteflexion, frequently associated with a 
small and conical cervix. Stenosis of the cervix may occur, or the cervix 
may be arrested in its development, even though the remainder of the 
genital tract is well formed. There may be congenital elongation of the 
cervix. The various forms of malposition and development defects become 
manifest only at puberty, when menstruation is established. 

The Vagina. — Complete absence of the vagina (defectus vagincc) is gen- 
erally confined to non-viable monstrosities ; in other apparent cases the vagina 
is represented by a rudimentary cord. The external genitalia may appear 
to be normal. Double vagina is very rare (Fig. 30). A unilateral vagina is 
generally associated with a unicornate uterus. The canal is narrow, and 
runs to one side of the median line. 

Atresia or stenosis of the vagina may be congenital or result from injury. 




FlG. 30. — Double vagina and double cervix. 



DEVELOPMENTAL ANOMALIES 



19 



Complete congenital atresia occurs only in association with arrested de- 
velopment and atresia of the other branches of the Miillerian ducts (Fig. 
31, a). As a rule, when the uterus is normal, congenital atresia of the vagina 
affects but a limited portion, and appears as a membranous closure of the 
lower end of the canal. Occasionally the upper third of the vagina is reduced 
to a sinus no larger than the cervical canal, the portion of normal calibre end- 
ing suddenly at a distance of an inch or more from the cervix. Atresia of a 
major part, associated with otherwise normal genitalia, is usually acquired, 
and may be due to bruising or laceration during coitus or labor, or to vaginitis 
complicating gonorrhoea, scarlet fever, diphtheria, typhus or typhoid fever, 
measles, cholera, and small-pox in early life. It may also follow faulty use of the 
pessary or be due to caustic, burns, scalding, and various diseases, such as 




Fig. 31. — (.4) atresia of vagina; (B) showing manner of closing wound after removal of 

obstructing septum. 



lupus, syphilis, cancer, gangrene, etc. True atresia of the vagina must be 
distinguished from simple cohesion of the vaginal Avails, analogous to the 
condition sometimes observed affecting the smaller labia. The vaginal 
walls may be adherent throughout their entire length, but a simple digital 
examination will usually suffice to separate them. 

A septate vagina (Fig. 24) is one in which a fusion of the two Miillerian 
ducts in the vaginal area has not occurred. When the condition is well 
marked, the uterus is usually double, septate, or bicornate. Sometimes it is 
unicornate, with a second rudimentary horn, the corresponding half of the 
vagina being also rudimentary. The uterus may likewise be single, and 
communicate with but one of the vaginal canals, the other ending in a 
cul-de-sac. Both sides of the vagina may, however, communicate with a 
single uterus, the septum extending the entire length of the vagina, from 
the hymen to the fornix, its upper extremity being unattached. As a rule, 



20 



GYNECOLOGY 



the two canals lie side by side, one of them, usually the left, being a little 
in front of the other. One canal is usually a little larger than the other. 
The septum varies in thickness, and may be the seat of perforations ; it often 
displays considerable mobility, being easily displaced to one side, and thus 
escaping observation. The septum may also be short and band-like, or may 
run diagonally. Occasionally it takes the form of a mere projecting ridge 
on the vaginal wall. Associated with a vaginal septum may be a double 
vulva, but, as a rule, this is single. The hymen is usually single, although 
it may have two openings. Abnormal openings between the vagina and the 
rectum or the vagina and the urethra may be present. These are generally 
due to malformation of the vulva, the remains of the cloaca or of the uro- 
genital sinus tending to persist. 

The Hymen. — Atresia is the most frequent malformation of the hymen. 

When the remainder of the genital tract is 
normal, atresia is usually acquired, and is 
the result of inflammation. Double hymen 
may occur in association with a double 
vagina, and is rarely seen otherwise. With 
the ordinary vaginal septum the hymen is 
single. Many variations in form occur ; thus 
it may be crescentic or cribriform ; it may be 
sculptured ; the opening may be exceedingly 
small (Fig. 32), or the hymen may be rep- 
resented merely by a few poorly-developed 
papillae. Hypertrophy, abnormal rigidity, 
or abnormal elasticity of the hymen may be 
present. Cysts are rare, and usually con- 
genital. They may have their origin in the 
coalescence of hymenal folds, in distended 
lymph-spaces, in embryonal rests, or in se- 
baceous glands. Tumors of the hymen, such 
as sarcoma, angioma, and polyp, have been 
described. 

The Vulva. — All evidences of the vulva 
may be absent (atresia or defectus vulvce) in 
non-viable feti. In these cases the bladder, 
genital canal, and rectum communicate, and are greatly distended with urine. 
The skin is stretched evenly and unbrokenly from the pubis to the coccyx, and 
from one tuberosity of the ischium to the other. No perineal septum may be 
formed, so that the anus opens into the vestibule. This is the result of an arrest 
of development beginning at the stage when the openings of the rectum, 
bladder, and genital tract were common and undifferentiated. An infantile 
vulva is usually associated with poorly-developed internal genitalia and a gen- 
erally weak systemic development ; it is often associated with chlorosis. 
The labia are small and flat. The introitus is shallow and narrow. A double 
vulva is very rare. Hypertrophy of the clitoris and of the labia minora and 
adhesions of the prepuce of the clitoris and of the labia minora may be 
present. The adhesions between the smaller labia may be due to vulvitis 




Fig. 32. — Nearly imperforate hymen. 

(Case of Dr. J. Whitridge Williams.) 

Woman pregnant. 



DEVELOPMENTAL ANOMALIES 21 

occurring in early life as a complication of gonorrhoea, pneumonia, measles, 
scarlet fever, diphtheria, dysentery, or typhus fever. 

The Bladder and Urethra. — Complete absence and duplication of the blad- 
der are possible malformations, but are extremely rare. A persistent patency 
of the urachus may result in the formation of a vcsico-ambilical fistula. The 
uvachus may be the seat of a cyst of large size, resembling an ovarian or a 
parovarian cyst. Epispadias, a defect due to fissure or an absence of the 
upper wall of the urethra, may be present, although it is not so common as 
in the male. The bladder may be normal, but is usually involved. Asso- 
ciated with this condition there may be a permanent separation of the two 
halves of the symphysis pubis and a median fissure of the anterior abdom- 
inal and bladder Avails. The bladder is usually smaller than normal, and 
may appear as a red, slightly congested mucous surface prolapsed through 
the cleft (exstrophy of the bladder). The clitoris and the labia minora and 
majora are divided, the halves lying on each side of the opened urethra. 
Occasionally the labia may be absent. 

Hypospadias is a congenital defect of the lower wall of the urethra. It 
may be partial in degree or complete, as when the urethrovaginal septum is 
entirely absent. Associated with this condition there may be a failure of 
development of the perineum and a persistence of the cloaca. If the hypo- 
spadias is simple — as is usually the case — the perineum is present. 

Malformations of the Ureter. — The most frequent abnormality of the 
ureter consists in a duplication of the duct. It may be unilateral or bilateral, 
and partial or complete. Congenital absence of a kidney is usually accom- 
panied by an absence of the corresponding ureter. Partial stricture or 
complete occlusion may occur in conjunction with an atrophic or cystic kidney. 
There may be an abnormal communication of the ureter with the vagina, 
rectum, urethra, or vestibule. 

Malformations of the Kidney. — The kidney of one side may be absent 
or rudimentary in structure, the accessory organs of the same side being 
also usually defective. The kidney may be of the fetal type, or small and 
lobulated. Absence of both kidneys is, of course, incompatible with life, 
and is found only in monstrosities. Various forms of fused kidneys are 
found, the commonest being the horseshoe kidney, in which the upper or 
lower poles are fused, forming a half-moon-shaped organ ; or the lower 
pole of one kidney may be fused with the upper pole of another kidney, one 
organ lying directly above the other, or the fused kidney may be repre- 
sented by a flat, disciform, cake-shaped body. 

Malformations of the Anus and Rectum. — Complete absence of the anus 
is rare. An imperforate anus is due to a persistence of the anal membrane 
separating the ectoblastic indentation from the rectal pouch (Fig. i, b). Stenosis 
of the anal canal, causing obstruction or constipation, may occur in an anus 
that presents a normal appearance externally. The anal opening may occupy an 
abnormal position in the sacral, lumbar, or pubic regions. Imperfect or in- 
complete fusion of the anus and rectal pouch may give rise to partial occlu- 
sion of the rectum. Failure of the two canals to unite, with varying degrees 
of separation, may occur. Such a condition may simulate an absence of the 



22 GYNECOLOGY 

rectum, the true condition being revealed only at operation. The rectum 
may communicate abnormally with the vagina, uterus, or other viscus, 
whereas the anus may be normal. 

PSEUDOHERMAPHRODISM 

Considered in its literal sense, the term " hermaphrodite " is applied to 
an individual who possesses perfect male and female generative organs. 
Although the condition has been observed in some species of vertebrates, in 
man the existence of true hermaphrodism has not been clearly established, 
since in most of the reported cases the details of microscopic examination 



3^ 




Fig. 33. — Gynatresia. Bulging impenorate hymen, simulating large cystocele. 
case as Fig. 34. (Bryn Mawr Hospital.) 



Same 



of the sexual organs have been lacking. Clinically, we are concerned chiefly 
with establishing definitely the sex of one in whom developmental defects 
of the external genitalia bring about a close resemblance of the organs to 
those of either sex. In 90 per cent, of the reported cases the condition is one 
of male pseudohermaphrodism. hence it is advisable that in doubtful cases 
the male sex should be assumed to exist. 

Female pseudohermaphrodism is a condition in which the ovaries are the 
essential sexual organs, the external genitalia and breasts, however. 
being imperfectly developed, and the habits, voice and pelvis being of the 
masculine type. The clitoris is enlarged, resembling the penis, and adhe- 
sions of the labia and labial ovarian hernia simulate the scrotum and its 



} 




DEVELOPMENTAL ANOMALIES 23 

contained testes. In these cases, owing to lack of development of the 
ovaries, menstruation may be absent. As is frequently the case, the ovaries 
may be located in the inguinal region, when they may resemble imperfectly 
descended testes. 

Male pseudohermaphrodism, as has been stated, constitutes the vast 
majority of cases of pseudohermaphrodites. The essential sexual organs, 
the testes, are present, but are poorly developed and often undescended. 
General male characteristics are absent, and the voice and figure, espe- 
cially the mammary development, conform more closely to the female type. 
The ill-developed external geni- 
talia resemble those of a woman. 
The penis is small, often held 
down by a frenum, and the urethra 
opens on the under surface (hypo- 
spadias). The scrotum may be 
deeply furrowed and resemble the 
labia. In extreme degrees the 
short vestibular canal may be 
guarded by a membrane closely 
resembling the hymen, and in 
some cases a uterus may be pres- 
ent, giving rise to an occasional 
sanguineous discharge resembling 
menstruation. In such cases the 
testes are incapable of producing 
spermatozoa, and, as a rule, 
pseudohermaphrodites are sterile. 
The removal of a sexual gland for 
the relief of pain or for some 
pathologic condition will afford 
an opportunity for microscopic 
examination and permit definite „ „ T _. 

. x Fk;. .$4. — dynatresia. Imperforate hymen. Distention 

COncluSlOllS as tO the Sex tO be of vagina and uterus by retained menstrual fluid — abdom- 
, inal tumor. (Brvn Mawr Hospita.L) 

made. 

Gynatresia is a complete stenosis of any part of the uterovaginal canal. 
After puberty, if any functionating endometrium is present, an accumula- 
tion of menstrual blood takes place above the point of obstruction. Stenosis 
may be present in an otherwise perfectly-formed uterus and vagina, or in 
double formations of the different types. 

The symptoms of gynatresia appear only after puberty, and consist of 
menstrual molimina without the escape of menstrual fluid. Severe, cramp- 
like pains with a tendency to bear down may be present. After a time the 
accumulated secretion causes a dilatation of that part of the genital tract 
in which it is confined, and forms a cystic tumor (Figs. 33 and 34). Ordi- 
narily, the suffering is so great and the development - of the tumor so prompt, 
that surgical aid is sought within a few years after puberty, although cases 
are on record that have gone on for many years. The severity of the 
symptoms is naturally dependent upon the physiologic activity of the 




24 



GYNECOLOGY 



ovaries producing the menstrual impulse, and upon the degree of develop- 
ment of the endometrium, to which the amount of menstrual fluid is directly 
proportionate. The simplest form of gynatresia is that which results from 
an imperforate hymen. In this condition the accumulating menstrual fluid 

first distends the vagina (hccmatocol- 
pos) (Fig. 35), and later, if the atresia 
is not relieved, the uterus. At first 
the cervical canal is involved (hcemato- 
trachelos) (Fig. 36), and finally the 
body of the uterus (hccmatometra) 
(Fig. 37) is afTected. The distended 
uterus preserves its hour-glass form 
for a long period, owing to the re- 
sistance to distention at the internal 
os. The uterine wall is either over- 
stretched and thinned to a marked de- 
gree, or the distention of the uterine 
cavity may be accompanied by hyper- 
trophy of the uterme walls. The 
menstrual fluid forces its way out into 
the tubes, and their abdominal ostia 
become occluded by a localized peri- 




Fig. 35. — Haematocolpos 



rx 



Fig. 36. — Haematotrache- 
los; haematocolpos. 



tonitis induced by the escape of tin 



fluid onto the pelvic 
peritoneum. The 
tube then in turn be- 
comes distended, form- 
ing a hematosalpinx 
(Fig. 38). 

Gynatresia may af- 
fect one side of a 
double or bicornate 
uterus (Figs. 39 and 
40). It is usually 
found in connection 
with rudimentary de- 
velopment of one side. 
If malformation of the 
uterus is associated 
with malformation of 
the vagina, the cystic 
tumor may affect both 
the uterine horn and the 
corresponding vaginal half. The tube on the affected side may also be the 
seat of a hematosalpinx. The retained fluid is thick, almost black in color, and 
of tar-like consistency. In long-standing cases inflammatory complications 
may ensue, and a hematosalpinx is frequently complicated by chronic pelvic 
peritonitis with adhesions. The encysted blood may become infected either 




Fig. 37. — Haematometra; 
haematotrachelos; haemato- 
colpos. 



Fig. 38. — Haematosalpinx; haematometra; 
haematotrachelos; haematocolpos. 



DEVELOPMENTAL ANOMALIES 



25 



by continuity from the adjacent intestine, or by way of the blood-stream, in 
the case of haematocolpos and haematometra, or infection may be secondary 
to spontaneous rupture of the occluding hymen and partial evacuation of 
the retained fluid. 



THE DIAGNOSIS OF MALFORMATION OF THE GENERATIVE ORGANS 

Abnormalities of the external genitalia are easily recognized. The diag- 
nosis of malformations of the ovaries and tubes by physical examination is 
very often quite impossible, and one is forced to rely on the general indica- 
tions of a defective ovarian activity. Incomplete ovarian development is 
manifested by an absence of the ovarian stimulus to the general system at 
the time of puberty. The change in configuration does not take place, the 
individual retaining the physical characteristics of childhood. Various 
neuroses may develop, 
anaemia is often present, 
and the general nutrition is 
poor. Hypertrichosis may 
be present. When the 
ovaries are rudimentary, 
severe pain referred to the 
ovarian region may occur 
at the time of menstruation. 




Fig. 39. — Gynatresia of one-half 
of double uterus and double va- 
gina. Haematometra; haemato- 
colpos. 



Fig. 40. — Gynatresia of one 

uterus and hagmatometra in 

double uterus. 



Faulty development of the 
uterus and vagina, the 
ovaries being affected coin- 
cidentally or not, may mani- 
fest itself in the form of 
amenorrhcea, dysmenor- 
rhea, sterility, or impo- 
tence. Double malforma- 
tions, in the absence of 
atresia, may remain undis- 
covered until pregnancy or 
labor makes a pelvic examination necessary. 

Malformations of the uterus and vagina may be divided into two large 
groups: (1) Those due to arrested development, and (2) those due to 
double development. 

Arrested Development of the Uterus and Vagina. — There may be 
simple atresia of the vaginal orifice, or the vaginal canal may be unde- 
veloped throughout its entire length. A rectal examination, made with a 
sound in the bladder, will serve as a means of differentiating between the 
two conditions. If the vagina is rudimentary, a few fibrous cords will be 
felt between the rectum and bladder. In simple occlusion after the age of 
puberty, the vagina is distended with blood, unless the generative organs 
are so deformed as to prevent a menstrual flow (see Gynatresia). The 
vagina may be occluded at a higher point, so that externally a short cul- 
de-sac may be observed. The distinguishing features between simple 
membranous occlusion and complete lack of development above this point 
are as follows : a rudimentary uterus may be recognized by making 



26 GYNECOLOGY 

careful bimanual examination with one finger in the rectum. A small 
body may be felt in the median line, with thin, cord-like branches run- 
ning on either side to the pelvic wall. On the other hand, nothing may 
be palpable in the median line, the lateral parts of the rudimentary bicornate 
uterus being made out by manoeuvres similar to those employed in picking up 
the ovaries and tubes. The lateral rudiment may often be mistaken for an 
ovary, and can be distinguished from the latter Only by locating both the 
rudiment and the ovary of the same side. Complete absence of the uterus 
in the adult is extremely rare. When the uterus remains in its fetal or 
infantile state of development, the external os may open directly into the 
vaginal vault, the vaginal cervix being barely perceptible. The length of 
the endometrial cavity may be determined by means of a sound, which will 
also afford some measure of information as to possible endometrial func- 
tion. The entire uterus may have a length of from 4 to 5 cm. Puberty is 
delayed for several years. The intermenstrual periods may be prolonged 
from several months to a year. The menstrual flow may appear for a day, 
or even for only an hour, and be accompanied by severe dysmenorrhea. 
Vicarious menstruation has been observed. The cervix is usually ante- 
flexed. The subject is of a nervous, unstable temperament. Conception 
rarely occurs, but is possible, especially after artificial dilatation of the 
cervical canal. Labor is marked by inertia uteri. 

Double Formation of the Uterus and Vagina. — If gynatresia is absent, 
no symptoms present themselves, and the condition remains unrecognized 
until pregnancy or abortion makes a pelvic examination necessary. Men- 
struation, pregnancy, and labor may occur as when the uterus is normal. 
When pregnancy takes place in one horn, the other becomes slightly en- 
larged. Labor may be complicated by weak contraction of the pregnant 
horn, or the unimpregnated horn, or a septate vagina may present an 
obstacle to the descent of the head. If the uterus is double but the two 
horns are not equally developed, and especially if one is atresic, the condi- 
tion will become apparent soon after puberty by the development of symp- 
toms of gynatresia. Double or septate vagina may be easily recognized if 
there is a double introitus; but if one side is rudimentary, the septum 
being considerably to one side of the median line, the condition is not 
readily recognized and may escape observation. Some difficulty may be 
experienced in recognizing septa situated high in the vagina. Whereas a 
double vagina is usually an indication of a double uterus, a double cervix 
invariably means a double uterus — uterus didelphys or uterus bicornis duplex. 
In bicornate uteri the cervix is generally single, the division between the two 
horns beginning above the external os. An attempt at diagnosis may be 
made by introducing the finger into the cervix, if this is patulous, or by 
passing two sounds, one being deflected to the right and the other to the 
left. Furthermore, bimanual pelvic examination will usually reveal broad- 
ening and furrowing of the uterine fundus. Double uteri may simulate a 
myomatous uterus, differentiation being made only with difficulty. A uterus 
with one horn (uterus unicornis) may be suspected when the organ lies with 
its fundus directed to one side of the median line, the body being long and 
thin, and the fundus being of neither normal size nor roundness, but taper- 



DEVELOPMENTAL ANOMALIES 27 

ing toward the tube. It may occupy a nearly transverse position. There is 
always a rudimentary or undeveloped horn, which may be felt on the side 
opposite to the uterus, and may be mistaken for the ovary or for a myoma. 
It is generally understood that a true single-horned uterus is not found in 
the adult, the real condition being one of double or bicornate formation, 
one side being rudimentary to an extreme degree. 

Diagnosis of Gynatresia. — If haematocolpos is present, there is a bulging 
outward of the hymen between the labia (Fig. 33), and a bluish discoloration 
is apparent. When the cystic tumor also involves the uterus, the distended 
fundus may be felt as a semi-cystic tumor extending above the symphysis. 
Hematosalpinx in conjunction with hsematometra is not easily detected. In 
order to determine the condition of the tubes an examination should be 
made, preferably by the rectum, under anaesthesia, and with great gentle- 
ness. Palpation will reveal the presence of sausage or retort-shaped cystic 
masses on one or both sides of the uterus. Gynatresia associated with 
double formation of the vagina and the uterus sometimes presents the greatest 
difficulties in diagnosis, since, as the fluid accumulates, the distended 
uterir- horn and vaginal portion lose all their original relations. The shape 
of the ^ystic tumor is approximately round or oval. It forms an elastic or 
firm mass, which is often quite sensitive and may be adherent to the sur- 
rounding structures. Its relation to the undistended horn and vagina de- 
pends upon the extent and nature of the malformation. Thus an accumula- 
tion of menstrual fluid in a rudimentary horn may be situated at such a 
distance from the developed horn that the examiner may mistake it for an 
ovarian tumor ; on the other hand, an atresia of one-half of a uterus didelphys 
or a fully-developed uterus bicornis will result in the formation of a tumor 
that is closely connected to the other half of the organ. In uterus septus 
the retention tumor occupies a part of the uterus itself, and the empty half 
can be recognized only by the aid of the sound. When the vagina is double 
and one side is atresic. but is in communication with one side of a deformed 
uterus, a fluctuating tumor lying to one side of the median line may reach 
nearly or quite to the vulva. 

THE TREATMENT OF MALFORMATION OF THE GENERATIVE ORGANS 

Atresia of the labia minora, the result of cohesion during early life, may 
be treated successfully by gentle separation of the parts, the pressure of a 
finger or the use of a probe generally being all that is required (see Diseases 
of the Vulva). Hypertrophy of the clitoris, labia minora, and prepuce may 
be dealt with surgically, the excess of tissue being removed, and the wound 
being closed by a suitable plastic operation. An imperforate hymen asso- 
ciated with haematocolpos should be excised. A rigid hymen may require 
forcible divulsion under anaesthesia, or, in extreme cases, excision may 
be necessary. 

Epispadias and hypospadias, if not too marked, are amenable to opera- 
tive measures, and if the condition is associated with incontinence of urine, 
surgical treatment should always be attempted. A defective urethra may 
be restored by uniting freshly denuded adjacent surfaces over a sound, just 
as in similar operations on the male. In extreme cases of epispadias asso- 



28 GYNECOLOGY 

ciated with exstrophy of the bladder relief may be obtained by excising the 
bladder and implanting the ureters with their vesical orifices into the 
rectum. In extreme cases of hypospadias the operation must be similar to 
that performed for marked cases of vesicovaginal fistula. 

Vaginal adhesions resembling those that form between the labia minora 
may sometimes simulate true atresia. In such cases separation may usu- 
ally be effected by the finger or a probe, the surfaces being held apart by 
packing or a suitable plug. When partial and limited in extent, vaginal 
atresia may be relieved by surgical measures. The atresic area should be 
excised, and the mucosa of the vagina above united to the mucosa of the 
vagina below, in order to insure continuity of the vaginal tube (Fig. 31, b) . 

If the atresia is complete, and if it is associated with imperfect develop- 
ment of the internal genitalia, so that no menstrual fluid accumulates, opera- 
tion should not be undertaken. If the condition is discovered after marriage, 
the question of operative interference becomes more pertinent, and oper- 
ative measures to restore the vagina may be undertaken. 

The operation for complete atresia consists, first, in making a dissection 
between the rectum and the bladder up to the site of the cervix, the pro- 
cedure being carried out following careful palpation per rectum with a 
sound in the bladder. When communication has been established between 
the cervix and the vulva, the opening should be enlarged as much as possible, 
by means of dilators. An attempt may be made to form a vaginal mucosa 
by transplanting flaps of skin from the adjacent parts of the vulva or but- 
tocks. Suitable packing, glass or silver plugs, or repeated dilatation may 
be employed in the endeavor to keep the newly-formed vagina open, but, as 
a rule, the operation is not followed by good results. Baldwin's plan of 
making an artificial vagina consists in transplanting an excised loop of 
ileum still attached to its mesentery, into a space created by dissection be- 
tween the rectum and the bladder. For the details of the operation the 
reader is referred to the original articles of Baldwin. Stewart and Marshall 
report favorable results following this operation in expert hands. Twenty- 
two cases have thus far appeared in the literature, and the results have been 
generally satisfactory. No deaths occurred. 

Vaginal septa should be excised, the procedure being usually carried 
out without any difficulty. The dividing septum should first be split through 
its entire length, and then each half should be removed by cutting through 
its attachment to the vaginal walls. The linear wound thus made should be 
closed by a catgut suture. 

Complete atresia or stenosis of the cervix requires dilatation of the 
cervical canal or amputation of the cervix above the site of obstruction. 
Partial atresia or stenosis is also an indication for dilatation (see Pathologic 
Anteflexion). Defective development of the cervix and uterus, whatever 
the type, is influenced but little by any mode of treatment. The more faulty 
the development, the less likely is treatment to be of any avail (see Dys- 
menorrhea). In cases of infantile uterus associated with stenosis of the cervix 
and anteflexion, the introduction of intrauterine pessaries and the intra- 
uterine application of the faradic current have been recommended, but their 
effectiveness is doubtful. Bicornate or double uteri often require no treat- 



DEVELOPMENTAL ANOMALIES 29 

ment, for, as has previously been pointed out, these conditions may give 
rise to no symptoms, menstruation, pregnancy, and labor occurring as in 
the case of the normal uterus. If, however, one horn is obstructed or un- 
developed, it may become distended with retained menstrual fluid or be the 
seat of a pregnancy. Distention of one horn with menstrual fluid is a form 
of gynatresia, and its treatment will be described further on. When preg- 
nancy occurs in an undeveloped or a rudimentary horn of the uterus the 
danger of rupture is great. For this reason the entire uterus, or the affected 
horn, should be removed as soon as the diagnosis has been made. Painful 
menstrual molimina without menstrual discharge, or with vicarious men- 
struation, may be an indication for the performance of bilateral oophorec- 
tomy. This operation is, however, indicated only when the uterus, vagina, 
and external genitalia are rudimentary or are so poorly developed as to 
render them entirely useless as organs of procreation. Hermaphrodism is 
not, as a rule, influenced or benefited by any form of treatment. In certain 
cases plastic operations on the external genitalia may be undertaken, but in 
most cases they are void of results. Hermaphroditic children, as stated else- 
where, should always be reared as males. 

The treatment of gynatresia depends upon the site of the closure and the 
extent of the menstrual accumulation. Before puncturing a vaginal or a 
cervical septum, an attempt should be made to ascertain the condition of 
the tubes, for if these are distended with blood, puncture alone would be 
useless and even dangerous. The thick, tarry fluid cannot be evacuated 
from the tubes in this way, and in spite of every precaution the tubal con- 
tents are likely to become infected and may lead to septic peritonitis. 
If the tubes are distended an exploratory abdominal incision should be 
made, and if the tubes are found to be badly diseased, they should be re- 
moved. If it appears feasible technically and sepsis is not present, the 
tubes may be opened, irrigated, and drained, and then left in situ after new 
ostia have been fashioned (see Salpingostomy). The site of the atresia 
may then be punctured from below, and the accumulated fluid carefully 
removed with pledgets of gauze. As the uterus and vagina are emptied 
their walls contract. The opening that has been made should be rendered 
permanent by a suitable plastic operation and the insertion of a glass or 
metal tube, or by repeated packing. If the cervix was the site of atresia, 
repeated dilatation of the canal with bougies may be necessary. In some 
cases it is wiser to amputate the cervix above the site of the atresia. When 
the tubes are involved and the uterus is malformed, removal of both the 
uterus and the adnexa is advisable in some cases. Whatever the operation 
or treatment carried out, the most rigid aseptic technic is required. 

THE SURGICAL TREATMENT OF CONGENITAL MALFORMATIONS OF THE ANUS 

AND RECTUM 

In cases of simple occlusion of the anal opening, as by membranous 
septa, the lower end of the tract is the seat of a more or less decided bulging. 
After the usual local preparations have been carried out, an incision is 
made carefully into the sac, and, after the contents have been evacuated, 
the redundant membranous septum may be cut away and the raw surfaces 



30 GYNECOLOGY 

covered in with continuous or interrupted catgut sutures. It may be 
necessary to continue the introduction of an anal dilator or a gauze drain 
for some time to prevent the formation of a cicatricial atresia. When 
there is no communication between the anal canal and the lower end of the 
rectum, end-to-end anastomosis is always to be considered, although the 
technical difficulties of this operation are great. A simpler plan consists in 
excising the anal canal, drawing the rectum down, splitting its blind end, 
and suturing the mucosa to the skin margins. When the rectum has been 
arrested high in the pelvis, the only guide to the rectal pouch may be a 
fibrous cord connecting it with the anus. Removing or dividing the coccyx 
may provide an avenue of access, or if the vagina is present, the approach 
may be made through this canal. Needless to say, care should be exercised 
to avoid opening the peritoneal cavity or injuring the bladder. When found, 
the blind end of the rectum may be brought out at the site of the external 
incision or the normal location of the anus. The blind end should be 
opened and the mucosa sutured to the skin margins. In imperforate anus 
in a feeble child, when the shock of a perineal dissection is likely to prove fatal, 
the operation of colostomy may be performed. The abdomen is opened, and 
a loop of intestine is brought up into the wound. But few sutures are 
needed, the intestine being supported in the wound by a glass rod ; later the 
blind end of the opened gut may be explored with a probe, thus facilitating 
the formation of a perineal opening. In some instances the rectum may 
open at an abnormal site, but this usually requires no interference. When 
the rectum opens into another viscus, plastic operations to meet the par- 
ticular condition at hand must be devised. 

BIBLIOGRAPHY 

Baldwin, J. F. : " Artificial Vagina by Intestinal Transplantation." Jour. Am. Med. Assoc., 

1910, liv, 1362. 
Marshall, G. B. : "A Review of the Various Operative Procedures for Correcting Atresia 

Vaginae." Jour. Obstet. and Gynec. Brit. Emp., 1913, xxiii, 193. 
Nagle, W. : " Entwickelung und Entwickelungs-Fe-hler der weiblichen Genitalien." Veits 

Handbuch der Gynakologie. Wiesbaden, 1897. 
Stewart, F. T. : " Formation of an Artificial Vagina by Intestinal Transplantation." Ann. 

Surg., 1913, lvii, 210. 
Winter, G., and Ruge, C. : Lehrbuch der gynakologischen Diagnostik. Hirzel, Leipzig, 

1907. 
Winter, G., and Ruge, C. : Gynecological Diagnosis, edited by John G. Clark. Lippincott, 

Phila., 1912. 

See also Bibliography, Chapter I. 



CHAPTER III 
ANATOMY OF THE GENERATIVE ORGANS 

The perineum is the region bounded by the pelvic arch, the tuberosities 
of the ischia, the anterior borders of the gluteus maximus muscles and the 
coccyx. It may be divided into two triangles by an imaginary line drawn 
between the anterior borders of the tuber ischii (Fig. 41). The anterior 
triangle is termed the urogenital, whereas the posterior is known as the 
rectal triangle. The rectal triangle comprises the ischiorectal fossae and the 




Fig. 41.— The division of the female perineal region into the urogenital and the 
rectal triangles. _ {U) urogenital triangle; (R) rectal triangle. (Semi-diagram- 
matic after photograph of patient in dorsal position.) 

anus; the urogenital triangle embraces the external genitalia, the external 
urinary meatus, the vaginal introitus, and the perineal body. 

The external genitalia are those parts of the reproductive apparatus that 
surround and protect the vaginal orifice. Collectively, these structures are 
known as the vulva. They consist of the mons veneris, the labia majora, 
the labia minora, the clitoris, the vestibule, the vestibular bulbs, and the 
glands of Bartholin (Fig. 42). 

The mons veneris is the anterior portion of the vulva. It consists of a 
thick mound or cushion of fat, supported by connective-tissue septa, over- 
lying the symphysis pubis. It is covered with a dense skin thickly over- 
grown with coarse, short hairs. 

31 



32 



GYNECOLOGY 



The labia majora are continuations downward, on both sides of the genital 
cleft, of the tissues making up the mons veneris. Each labium consists of 
a fold or lip of skin inclosing between its outer and inner surface fatty con- 



\GKer 







Pr^eputjurn 
clitfoiMis 

Glaus 'clitoris 

Labium'minus 

Labium 
majus 

(/retJu ! :2 




Hymen 



■MginaJ 
Wtfice. 

Fossa 
vicularjs. 



■Raphe permei 




Anus. 



Fig. 42. — Normal virginal vulva showing component parts. Sound pointing 
to opening of Bartholin's (vulvovaginal) gland. 

nective tissue and a few muscle fibres. The labia extend from the mons 
veneris in front to the perineal body behind, blending with the latter. Their 
outer skin is thick and pigmented, and contains numerous short hairs and 
sebaceous and sweat glands (Fig. 43). The inner cutaneous covering is of 
more delicate structure, and becomes continuous with the labia minora. 



ANATOMY OF THE GENERATIVE ORGANS 33 

The labia minora, or nymphcc, are concealed, in the erect posture, by the 
labia majora, with which they run more or less parallel. Anteriorly, each 
labrum divides into two layers that surround the glans clitoris, forming a 
prepuce and a frenum. From the clitoris the nymphse encircle the orifices of 
the urethra and the vagina, and bound the portion known as the vestibule. 
Behind the nymphse merge into the corresponding greater labium, and are 
connected to each other by a transverse fold of skin known as the fourchette. 
Both surfaces of the nymphse are covered with a delicate membrane that re- 
sembles mucous membrane in appearance, although it contains no mucous 
glands (Fig. 43). Numerous sebaceous glands are present on both sur- 
faces, and anteriorly, near the prepuce, sweat glands are seen. 

The clitoris is the homologue of the penis in the male. It is an erectile 
organ, formed by the junction of two cavernous bodies, each of which is 




Fig. 43. — Histology of various parts of the genital tract. Accompanying diagrams 
represent area from which sections were taken. See also figures 46, 53, 54, 55 and 56. 
Histology of labia of young child. Labia maiora on left covered with stratified 
squamous epithelium showing central fat. hair shafts, and sebaceous and svveat glands 
in external cutaneous surface. Labium minus on right showing stratified squa- 
mous cutaneous epithelial surface covering stratum of loose connective tissue and 
muscle fibers. (After Piersol.) 

attached to the pubic ramus of its corresponding side. The clitoris for the 
most part lies concealed in the subcutaneous tissues of the lower portion of 
the mons veneris. Only its extremity is visible as a small conical protru- 
sion known as the glans clitoris. This is situated in the median line, 
directly behind the mons veneris. Like the penis, it is supplied with a 
prepuce and a frenum, both of which are formed by the anterior portions of 
the labia minora. 

The vestibule is the space bounded by the nymphse, and containing the ex- 
ternal urethral and vaginal orifices. On each side, at the lower margins of 
the external meatus, are the openings of the para-urethral (Skene's) tubules. 
On each side of the vaginal introitus are the openings of the ducts of 
Bartholin's glands. The cutaneous covering of the vestibule is of the same 
delicate structure as that of the nymphse. 

The Glands of Bartholin. — These are situated one on each side of the 
vaginal orifice, and are embedded in the tissues of the corresponding labium 
3 



34 



GYNECOLOGY 



majus behind the vestibular bulb. They are about iy 2 by I cm. in size. 
Each gland has a duct that opens upon the surface of the vestibule, between 
the nymphae and the hymen, in the posterior third of the lateral border of the 
vaginal orifice. The site of the orifice may be marked by a small depression. 
The opening is very small, and can often be detected only by expressing a 
portion of the mucous contents of the gland. The gland is of the mucous 
tubo-alveolar type. The acini, as well as the duct, are lined with columnar 
epithelium. Xear the opening of the duct the epithelium becomes squamous 
in type. 

The para-urethral tubules (Skene's ducts) are two short ducts, 1-2 cm. 
in length, lined with columnar epithelium and situated one on each side of 
the posterior wall of the urethra. The tubules open 
upon a small elevation of the mucous membrane. The 
orifices are so minute as to be scarcely discernible in 
some cases. In virgins the tubular openings are fre- 
quently concealed by the close approximation of the 
lips of the meatus ; in women who have borne children 
a certain amount of eversion is present, which exposes 
the openings. At times instead of a single tubule, a 
number may be present on each side. These tubules 
have been regarded as the embryologic remains of the 
Wolffian duct. 

The vestibular bulbs are elongated masses of cavern- 
ous tissue that are embedded in the tissues of the 
labia and the lower end of the vagina and urethra. 
Anteriorly they are in relation with the cavernous 
bodies of the clitoris. They are analogous to the 
corpus spongiosum of the male. 

The vagina is the canal that forms the passageway 
between the external and the internal genitalia. It is a 
fibromuscular tube lined with squamous epithelium. 
It is flattened anteroposteriorly, the anterior and pos- 
terior walls being in contact for the middle and greater 
part of the lower third of its course. On cross-section 
it presents an H-shaped appearance, the vaginal wall 
being reduplicated on each side and along the pos- 
terior wall in what are known as the vaginal sulci. The 
vagina is directed upward and backward from the vaginal introitus. In the erect 
position its axis forms an angle of about 70 degrees, its general direction being 
more or less parallel to the line of the superior strait. Its lower part corresponds 
with the axis of the pelvic outlet. Its upper part surrounds and is attached to the 
projecting vaginal portion of the cervix uteri. The arched upper blind end of 
the vagina is known as the fornix, or vaginal vault (Fig. 44). The cervix 
projects into the vagina at what is approximately a right angle, so that its 
anterior attachment to the vagina is at a point further forward than the 
posterior attachments. This tends to make the anterior wall shorter (7 cm.) 
than the posterior wall (8.5-9 cm.). The vaginal orifice is narrowed by a fold 




Fig. 44. — Vaginal fornices: 

(P.F.) posterior fornix; (A.F.) 

anterior fornix. 



ANATOMY OF THE GENERATIVE ORGANS 



35 



of mucous membrane known as the hymen. The remains of the hymen after 
rupture are termed the carunculce hymcnales, or myrtiformes. The uppermost 
part of the posterior wall of the vagina, the posterior vaginal fornix, is con- 
tiguous to the bottom of the pouch of Douglas, and is covered by peritoneum. 
From the pouch of Douglas to the levator ani muscles the vagina and rectum 
are brought into close relation by the rectovaginal septum, which is strength- 




Fig. 45. — Sagittal section through young female body. BladderNempty, rectum slightly 

distended. 



ened by intervening prolongations of the pelvic fascia. Below the recto- 
vaginal septum ends in a wedge-shaped mass of tissue, the perineal body, 
whose base corresponds to the surface of the perineum and separates the 
vaginal introitus from the anus. In its upper fourth the anterior vaginal wall 
is related to the trigone of the bladder ; at the level of the lower end of the 
cervix on each side it is in close relation with the ureters ; further down it is 
intimately connected with the urethra (Fig. 45). At the sides the vagina is 



36 



GYNECOLOGY 



surrounded and supported by the median portion of the levator ani muscles 
and the pelvic fascia. Near the outlet the vagina is closely attached to the 
triangular ligament. The vaginal canal is lined with stratified squamous 




Fig. 46. — Histology of vaginal wall, showing stratified squamous epithelial 

surface and supporting connective tissue. (After Piersol.) „ 

epithelium, but contains no glands. The underlying connective tissue is 
beset with numerous papillae, but under normal conditions these do not affect 
the smoothness of the surface. Numerous transverse folds or elevations of the 






Fig. 47. — Anterior aspect of nulli- Fig. 48. — -Posterior aspect of nuili- 
parous adult uterus, showing peri- parous adult uterus, showing peri- 
toneal reflections. toneal reflections. 



mucosa known as rugae are observable. Small lymph-nodes are found within 
the mucosa, especially in the vaginal fornices (Fig. 46). 

The uterus is made up structurally of a neck, or cervix, and of a body, or 



ANATOMY OF THE GENERATIVE ORGANS 



37, 



corpus. It measures 7 cm. in its entire length, of which the cervix constitutes. 
2.5 cm. Its greatest breadth is about 4 cm., and its thickness about 2.5 cm. In 
women who have borne children the various dimensions of the uterus are. 
increased about 1 cm., the cervix, however, being relatively shorter than before 
pregnancy. The upper extremity above the Fallopian tubes is known as the 
fundus. The anterior surface is more flat and less r 
convex than the posterior surface (Figs. 47, 48 
and 49). That portion of the cervix that lies be- 
low its attachment to the vagina and projects into 
the vaginal fornix is known as the portio vaginalis; 
that w r hich lies above the vaginal attachment is 
known as the portio supravaginalis. 

The uterine canal begins at the center of the 
vaginal cervix in the form of a rounded, sunken 
opening, known as the external os. The cervical 
canal begins at the external os, and extends to the 
point of junction of the cervix with the body of 
the uterus, which is indicated by a contraction of 
the canal known as the internal os. Between 
these points, in longitudinal sections, the canal 
appears to be fusiform, being widest in the middle 
of its course. The cavity of the uterus is flattened 
anteroposteriorly, the anterior and posterior walls 
lying in contact, so that in sagittal sections it appears 
as a mere cleft (Figs. 50 and 51). When, however, the uterus is divided by a 
transverse incision, the endometrial cavity is seen to be triangular in shape, the 
base of the triangle being directed toward the fundus and the apex toward the 
internal os. The greatest width of this cavity is at the fundus, where it 




Fig. 49. — Lateral aspect of nulli- 

parous adult uterus, showing 

peritoneal reflections. 




Fig. 50. — Transverse section of uterus at fundus, showing the endometrial cavity and the myo- 
metrium at the level of the tubal orifices. (After Waldeyer.) 



measures 2.5 cm. In the erect posture the uterus is nearly horizontal, its anterior 
surface and body resting upon the bladder (Fig. 52). The fundus is elevated 
and pushed slightly backward by distention of the bladder. The axis of the 
cervix forms an obtuse angle with the axis of the body. The entire uterus 
moves forward and backward through an imaginary transverse axis pass- 



38 



GYNECOLOGY 



ing from side to side through the internal os. Whatever moves the fundus 
backward throws the cervix forward, and vice versa. The cervix is more 
securely fixed in its position than the fundus, and when the uterine muscle 
is relaxed and flabby, movements of the fundus may not influence the posi- 






FiG. 51. — Transverse section of the uterus above the internal os, showing the relations between 
the endometrial cavity, the uterine muscle and the parametrial tissues. (After Waldeyer.) 




Fig. 52. — Para-sagittal section of the pelvis, showing relation of ureter to 
bladder, cervix, vagina, and rectum. (After Tandler and Halban.) 

tion of the cervix, the angle of flexion between the body and the cervix 
changing constantly. The fundus of the uterus lies a little to the left of the 
median line. The posterior surface of the uterus is usually covered by the 
small intestines and the sigmoid flexure. Between the rectum and the pos- 
terior surface of the lower uterine segment lies the pouch of Douglas. The 



ANATOMY OF THE GENERATIVE ORGANS 



39 



anterior surface of the lower uterine segment is attached to the bladder, 
the peritoneal covering of the uterus at either side fusing into the anterior 
and posterior leaflets of the broad ligament. 

The mucous membrane of the vaginal cervix is continuous with that of 
the vaginal fornices, and is of the stratified squamous variety of epithelium. 
At the external os the epithelium assumes the high columnar type, covering 
the reduplications of the submucosa and lining the cervical glands and ducts. 
The cervical glands are of the racemose type. They contain a thick, tena- 
cious mucous secretion. The mucous membrane of the cervical canal is 
marked by conspicuous ridges or folds consisting of a primary median 
longitudinal fold, running along the anterior and posterior wall, and numer- 
ous secondary folds, running outward and upward from the primary fold 
(Fig. 53). At the internal os the character of the mucous membrane changes, 



Recess 

between 

folds 

containing 

secretion 

Fold of 
mucosa 




1. 1'. . ■! r £■'■■-.- -t"..f ~*--', ji \.-_r/..VZJ\ 

Fig. 53. — Histology of cervix, showing papillary arrangement of cervical folds 
and high columnar epithelium lining the cervical glands. (After Piersol.) 

and from this point upward throughout the uterine cavity a highly special- 
ized mucous membrane, known as the endometrium, extends. The endo- 
metrium is about 1 mm. in thickness, and consists of a stroma of small, round, 
so-called lymphoid cells. It is rich in blood-vessels, and is penetrated by 
glands that extend from the surface to the deepest part of the endometrium, 
which is in close relation with the myometrium. Many of the glands pene- 
trate the innermost layers of the uterine muscle (Fig. 54). The endometrial 
glands are of the tubular variety, and, as a rule, show two branchings in their 
depths. The lining consists of epithelium of the cuboid type— a continuation 
of the surface epithelium. The secretion is less thick and tenacious than 
that of the cervical mucosa. The endometrium is continuous with the 
cervical mucosa at the internal os, and with the mucosa of the Fallopian 
tubes at their inner ostia. 

The blood-vessels of the endometrium consist of capillaries, and form a 
rich anastomosis in the superficial stratum of the endometrium beneath the 



40 



GYNECOLOGY 



surface epithelium — the subepithelial capillary plexus. It is from this plexus 
that the menstrual fluid is derived. 

The myometrium is composed of interlacing bundles of muscular and 
fibrous tissue that form three layers : an outer or subserous layer, whose 
general direction corresponds to the long axis of the organ ; an inner layer, 
which is disposed in a circular manner about the uterine cavity, and a 
middle layer, known as the vascular, which is the thickest and most im- 
portant of the three. In this layer the muscular and fibrous tissue bundles 
are interlaced, running in every direction, and inclosing between them the 
veins and arteries, upon which, by contraction, they exert a controlling in- 
fluence. The outer surface of the uterus, with the exception of the lower 





Fig. 54. — Histology of endometrium of body of uterus, showing stroma and the 

tubular glands lined with low columnar cells penetrating the innermost layers of 

the uterine muscle. (After Piersol.) 

part of the anterior surface of the fundus and the cervix, is covered with 
peritoneum. The lower anterior limit of the peritoneum is marked by the 
peritoneal reflection to the bladder. 

The Fallopian tubes are fibromuscular canals covered with peritoneum 
and lined with mucous membrane. They extend from the fundus of the 
uterus on each side to the corresponding ovary. They are about 11.5 cm. 
in length. The inner third, or isthmus, is narrow ; the outer two-thirds, or 
ampulla, is broad and expanded. The outer extremity of the tube is open, 
presenting a trumpet-shaped orifice known as the infundibulum or abdom- 
inal ostium. On its outer surface the tube is invested with peritoneum 
derived from the superior border of the broad ligament, this particular fold 
of peritoneum being known as the mesosalpinx. The peritoneal coat ends 



ANATOMY OF THE GENERATIVE ORGANS 



41 



at the abdominal ostium, where it comes into relation with the mucosa. The 
mucosa of the tube has a peculiar arrangement : at the uterine end it is com- 
posed of a few reduplications of a fibrous submucosa. covered with columnar 
epithelium ; the reduplications increase in number toward the outer ex- 
tremity, so that a cross-section made at this point shows the tubal lumen to 
be obstructed with branching, tree-like projections of the submucosa cov- 
ered with a single layer of columnar cells. At the outer ostium these folds. 
covered with epithelium, project and form what are known as the fimbriae. 
One or two of these are usually longer than the others, and are attached or 
lie in close relation to the ovary — the ovarian fimbriae. The tubal mucosa is 
directlv continuous with the endometrium at the uterine ostia of the tubes, 




Longitudinal muscle 



Fig. 55. — Histology* of Fallopian tube. Transverse section of tube near outer end of ampulla, showing the 
tree-like branchings of the plica of the mucosa, the inner circular and outer longitudinal muscle layers. 

'After Piersol.) 

and with the pelvic peritoneum and capsule of the ovary at the abdominal 
ostium. The middle coat of the tube is made up of muscular tissue arranged 
in two layers — an outer longitudinal and an inner circular layer (Fig. 55). 
The lumen of that portion of the tube lying within the uterine wall is 1 mm. or 
less in diameter, gradually increasing toward the ampulla, where it meas- 
ures from 2 to 4 mm. ; at the abdominal ostium it is from 4 to 6 mm. in 
diameter. The outer diameter of the tube at the isthmus is between 3 and 4 mm., 
whereas at the ampulla it measures from 6 to 8 mm. 

The tube passes from the uterus toward the ovary, encircling the latter, 
its fimbriated extremity being in relation usually with the lower and back 
part of the median surface. The ovary is also partly enveloped by the 
mesosalpinx, the peritoneal reflection in which the tube is inclosed. Viewed 
from above, the ovarv is often concealed by these structures. The close 



42 



GYNECOLOGY 



approximation of the mesosalpinx, forming a sort of pocket, and the proximity 
of the fimbriated extremity facilitate the entrance of the fecundated ovum 
into the Fallopian tube. These relations may, however, be disturbed by 
malpositions of the uterus or by the interposition of portions of the intestines. 
The ovaries, or sexual glands, are oblong, almond-shaped, solid bodies 
attached to the posterior surface of the broad ligament. Their average 
dimensions are 36 by 18 by 12 mm., although they vary in size from time to 
time with the development and rupture of the Graafian follicles. The area 
of attachment to the broad ligament is along the anterior border of the 
ovary, a portion known as the hilum. Although the peritoneum of the pos- 




Follicle begin- 
ning to grow 



Theca' 



Fig. 56. — Histology of ovary, showing surface epithelium, and follicles in various stages of development within 

the ovarian stroma. (After Piersol.) 



terior surface of the broad ligament immediately surrounds the area of ovarian 
attachment, it is not continued over the surface of the ovary itself, so that 
the capsule of the organ is in direct relation with the peritoneal surfaces of 
the pelvis and the ovary is intraperitoneal. 

The ovary is suspended vertically by the infundibulopelvic ligament, a 
derivative of the broad ligament, which passes outward over the external 
iliac vessels to the fascia covering the psoas muscles. Within this ligament 
lie the ovarian vessels and nerves. The inner or lower pole of the ovary is 
attached to the posterior surface of the body of the uterus, behind and 
below the isthmus of the tube, by the utero-ovarian ligament. This is envel- 
oped by the peritoneum covering the posterior surface of the broad ligament. 
The ovary is made up of a fibrous tissue stroma that contains resting or 
developing ova (Fig. 56). The resting ova are seen in large numbers in the 



ANATOMY OF THE GENERATIVE ORGANS 43 

peripheral zone of the organ. They develop one by one, forming Graafian 
follicles that rupture and discharge the ovum, the site of the follicles being 
filled in by a temporary structure known as the corpus luteum, which is 
succeeded in turn by hyaline bodies termed the corpora albicantia. These 
structures are all usually found at one time in the adult ovary, in various 
stages of development or retrogression. The core or central portion of the 
ovary is the vascular area. The capsule is formed by a condensation of the 
fibrous stroma, and presents a dull white, lusterless appearance. Under the 
microscope, here and there in depressions of the surface, low cuboidal cells — 
the germinal epithelium — are seen. 

The Bladder. — The bladder occupies a position between the uterus and 
the symphysis pubis (Fig. 52). It lies in contact with the space of Retzius in 
front, loosely attached to the cervix behind, and between them in close 
relation with the anterior vaginal wall, to which its base is intimately 
attached. The apex of the bladder is free. This is the portion that rises as 
the viscus fills with urine. When distended the bladder is pyriform in 
shape. As the urine is voided the apex or movable portion sinks into the 
base, a fixed part, just as one saucer fits into another. A sagittal section 
made at that time shows the organ to be triangular in outline, the base 
being directed upward, stretching between the uterus and the symphysis. 
and covered with peritoneum ; the anterior side is seen to be attached to the 
symphysis, and the posterior side is fused with the anterior vaginal wall. 
Viewed from above, the peritoneal surface of the bladder presents a cordi- 
form outline, the base stretching in front of the uterus mesially and on 
either side of the broad ligament, the two sides curving gently forward to- 
ward the symphysis pubis. The urethra emerges from the bladder at its 
lowest part, the internal urinary meatus, which forms the apex of a triangular 
area known as the trigone, the three points of the triangle consisting of 
the internal urinary meatus and the two ureteral orifices. This is the most 
fixed portion of the bladder, being intimately attached to the anterior 
vaginal wall. Although the mucosa covering the parts of the bladder which 
distend is thin and without rugse, the mucosa of the trigone is thicker and is 
thrown into ridges or folds that converge from the base of the trigone — the 
interureteric line — toward the apex — the internal urinary meatus. 

The average capacity of the normal bladder is 430 c.c, although it has 
been known to have a capacity of 750 c.c. Under pathologic conditions, the 
bladder may hold as much as three or four liters of urine without rupture. 

The body of the uterus rests upon the superior surface of the bladder; 
it rises with the distention and falls with the evacuation of that viscus. 

The Urethra. — The urethra is from i 1 /^ to iy 2 inches in length, and runs 
directly from the apex of the bladder to the external urinary meatus. It is 
intimately associated with the anterior vaginal wall. At the point where it 
leaves the bladder it is surrounded by circular muscular fibers — the vesical 
sphincter. The external meatus is slightly contracted, but possesses 
no sphincter. 

The Ureters. — The ureters are tubes, one on each side, which connect 
the renal pelvis with the bladder. They are about 10^2 inches long, the left 
being slightly longer than the right. The diameter of the tube varies in 



44 



GYNECOLOGY 



different parts of its course, but the average is between 4 and 5 mm. In the 
abdominal cavity the ureter descends from the kidney pelvis, beneath the 
peritoneum, overlying the psoas magnus muscle to the pelvic brim, where 
it is about 1 1/16 inches from the median line of the lumbosacral promontory. 
A little above the pelvic brim the ureter crosses the iliac vessels at about the 
point where the division into the external and internal iliac arteries takes 
place. It then follows the course of the internal iliac artery, running parallel 
with but posterior to it, until it reaches the pelvic attachments of the broad 
ligament, where it leaves the internal iliac and penetrates the connective 
tissue of the ligament from behind forward, curving from the pelvic wall 
toward the median line. It passes beneath the uterine artery and reaches 







1 : V v 










; \ ; ,* 










• tJSk 

' (fiff 


W^Cfca. 




^1 




IS^^p^ vr. 0. 







Fig. 57. — Interior of bladder and relation of ureter to uterine artery, showing trigone, ureteral orifices 
and internal urethral orifice; also the intimate relation of the ureter and uterine artery. (Ul.a.) uterine 

artery; (Ur.o.) ureteral orifice. 



the cellular space between the cervix, anterior vaginal wall, and bladder. It 
pierces the vesical wall obliquely, and empties into the bladder at the 
ureteral orifice (Fig. 57). 

The ureter receives its blood supply from the small branches of the renal 
and ovarian arteries, and from a special artery from the internal or common 
iliac, or from the aorta. In the pelvis the middle hemorrhoidal or the in- 
ferior vesical contributes branches whose twigs produce a network that sup- 
plies the ureteral wall. 

The pelvic ureter is surrounded by a sheath derived from the tissue 
along or through which the ureter passes. If, during operations, the integ- 
rity of the sheath is preserved, that of the ureter is assured. Separation of 
the ureter from its sheath deprives it of an adequate blood supply, and 



ANATOMY OF THE GENERATIVE ORGANS 45 

subjects it to the danger of ureteral necrosis. The position of the ureters as 
they approach the cervix and lie in intimate relation with the uterine artery 
and vaginal and vesical wall is of considerable importance surgically (Fig. 
57). Approaching the uterine artery and uterovaginal junction from the 
abdominal side, they lie below and to the outer side, and if the uterus is 
pulled forcibly up and toward the median line, the distance between the 
uterus and the ureters is increased. 

In vaginal operations the position of the ureteral orifices in relation to 
the anterior vaginal wall may be ascertained by selecting a point from 5 to 6 
cm. from the external meatus, in the midline. This corresponds to the posi- 
tion of the base of the trigone. The ureteral orifices are situated 1 to 1.25 
cm. to either side of the median line. In vaginal operations, when the an- 
terior fornix is divided and the cellular tissue between the vagina, cervix, 
and bladder is exposed, the ureters are carried up out of the operative area 
as the bladder is pushed off from the cervix and elevated by suitable retrac- 
tion. The distance between the cervix and the ureter is also increased if the 
cervix is pulled down with a tenaculum. 

The Rectum. — The rectum lies posterior to the uterus and vagina. It 
is separated from the uterus and from the fornices of the vagina by Douglas' 
cul-de-sac. The rectum is the terminal portion of the large intestine. It 
takes its origin in a point opposite the third sacral vertebra, or where the 
mesentery of the sigmoid flexure terminates. The rectum follows the curve 
of the sacrum and the coccyx to a point slightly below the top of the latter, 
where it meets and ends in the anal canal. The anterior wall of the rectum 
in the lower part, i.e., the part not covered by peritoneum, is intimately con- 
nected with the posterior vaginal wall. The lowest portion of the rectum, 
at the position of its junction with the anus, abuts upon the perineal body. 
With the anal canal the rectum forms nearly a right angle. 

The rectum is divided into three sacculations or pouches by the rectal 
valves. The latter are ridges or folds that project from the gut into its 
lumen ; they are caused by a folding or turning in of all the coats of the bowel 
covering two-thirds of its circumference. The largest of these pouches or 
sacculations is the lowest, which is known as the ampulla. The first valve 
can be felt at about a finger's length from the anus, and at a point almost 
opposite the posterior vaginal fornix. The anus is situated deeply between 
the folds of the nates, about two inches from the tip of the coccyx. In 
repose the orifice appears as a longitudinal slit, the skin surrounding the 
aperture being pigmented and thrown into folds or corrugations by the 
contraction of the external sphincter. The anus is separated from the 
vaginal orifice by the perineal body. The external sphincter muscle is intimately 
associated and blended with the fibers of the levator ani muscle, which 
surround the lower portion of the rectum. The fibers of the levator ani 
decussate with those of the middle coat of the intestine. 

The Pelvic Peritoneum. — The peritoneum of the anterior abdominal 
wall is continued downward into the pelvis. In front it is reflected over 
the apex of the bladder and the anterior surface of the uterus, to the upper 
half of which it is closely applied. Laterally it passes over and partly sur- 
rounds the round ligaments, forming the anterior leaflet of the broad liga- 



46 



GYNECOLOGY 



ment. From the superior border of the broad ligament at either side and 
the fundus of the uterus in the center, it passes down over the posterior 
surface, enveloping the Fallopian tubes laterally, and covering the entire 
posterior surface of the uterus. It lines Douglas' pouch, sweeping over the 
uterosacral ligaments to either side, and thence passing to the lateral .vails 
of the true pelvis. It surrounds the rectum for about two-thirds of its cir- 
cumference, being continuous with the lower folds of the mesosigmoid. 
These reflexions of the peritoneum, which may be likened in their forma- 



Perirectal fossa 



Uterorectal fossa 

or 
pouch of Douglas 



Uterovesical fossa r 




Perivesical fossa 



Fig. 58. — View of pelvis from above, showing relations of contained organs and peritoneal 



tion to a thin membrane blown into the pelvis and adjusting itself as a 
cover or support of its viscera, form certain fossae ; for example, between the 
bladder and the uterus, the uterovesical fossa; to either side of the rectum, 
the perirectal fossae, and posterior to the uterus, the uterorectal fossae or the 
pouch of Douglas. All these fossae are occupied normally by coils of the 
small intestine and the omentum (Fig. 58). 

The Uterine Ligaments. — The pelvic peritoneum is largely concerned 
with the formation of most of the so-called ligaments of the uterus. It 
enters into the formation of the broad, the uterosacral, and the uterovesical 
ligaments. These are principally made up of folds or of reduplications of the 



ANATOMY OF THE GENERATIVE ORGANS 



47 



peritoneum inclosing fatty areolar tissue and the lymphatic and vascular 
vessels supplying the uterus. Thus, the broad ligaments are made up of 
cellular tissue, a few smooth muscle-fibers, the ovarian and uterine vessels, 
with an anterior and a posterior peritoneal covering running from each 
side of the uterus to the corresponding pelvic wall (Fig. 59). The broad 
ligament is strengthened by its association with and peritoneal attachment to 
the round, to the utero-ovarian, and to the infundibulo pelvic ligaments, 
which contain particularly dense connective-tissue strands. The uterosacral 
ligaments are peritoneal folds running from the posterior surface of the 




Fig. 59. — Lateral sagittal section of female pelvis, showing anterior and posterior 
segments of pelvic floor. (C) center of perineum; this with the area in front of 
it constitutes the anterior segment and is chiefly supported by the triangular liga : 
ment; (P) posterior segment of perineum chiefly supported by the levator ani 

muscle. 

cervix just above its insertion into the posterior vaginal fornix, one on 
each side, around the lateral border of Douglas' pouch, and the rectum to 
the sacrum. They inclose connective-tissue prolongations from the broad 
ligament, smooth muscle-fibers, blood-vessels, and lymphatics. The utero- 
fesical ligaments are peritoneal folds running on each side of the vesico- 
uterine pouch from the lateral borders of the bladder to the uterus (Fig. 60). 
in structure. they resemble the uterosacral ligaments, but are less marked 
than the latter. Radiating from the neighborhood of the internal os, there 
are combined with the cellular tissue more or less well-defined fibromuscular 
and elastic bands. These serve as a part of the supporting apparatus of the 
pelvic viscera reinforcing the broad, uterosacral and uterovesical ligaments. 



48 



GYNECOLOGY 



At the base of the broad ligaments they comprise what are known as the 
cardinal ligaments — posteriorly, they form the supporting tissue of the utero- 
sacral ligaments, and anteriorly they give strength to the uterovesical ligaments. 
The round ligament, the only true ligament of the uterus, is made up of fibrous 
and muscular tissue. It is from 12 to 14 cm. long. It springs from the anterior 
surface of the uterus at a point in front of and below the tube, and runs within the 
upper part of the broad ligament to the pelvic wall. From this point it con- 
tinues its extraperitoneal course forward and upward, crossing the external 
iliac vessels, curving around the deep epigastric artery to the internal ab- 



External oblique muscle\ 
Internal oblique muscle \ 
Transversalis muscle \ \ \ 



-External ring 



Internal ring 

JxPoupart's 
ligament 

Round ligament 




\Broad ligament 



ffSWv. 

Fig. 60. — The supporting ligaments of the uterus and their relation to other pelvic structures. 

dominal ring. It runs through the entire inguinal canal, and is inserted into 
the subcutaneous tissue of the labia majora and the pubic spine. The 
proximal two-thirds contains muscular tissue derived from the uterine wall, 
but the distal third consists entirely of fibrous tissue. In the foetus a small 
peritoneal diverticulum usually accompanies the round ligament. This gen- 
erally disappears, but may persist as a distinct serous pouch, known as the 
canal of Nuck. 

The Pelvic Cellular and Connective Tissue. — At the sides and on the 
floor of the pelvis, between the pelvic peritoneum and the fascia over which 
it lies, there is a layer of loose fibroareolar tissue. This is known as the 
pelvic cellular tissue. In certain areas where, from reduplication of the 
peritoneum, a considerable interval occurs between it and the pelvic wall or 



ANATOMY OF THE GENERATIVE ORGANS 



49 



floor, this tissue is more abundant and forms a more or less distinct struc- 
ture (Fig. 61). These especially well-developed parts of the pelvic cellular 
tissue are designated with names that describe their position. Thus the 
cellular tissue lying between the peritoneal covering of the broad ligament 
and extending to the pelvic wall and to the pelvic floor is termed the 
parametrium. The cellular tissue between the folds of peritoneum which form 
the uterosacral ligaments and the pelvic floor and sacrum, is known as the 
paraproctium. The cellular tissue surrounding the upper portion of the 
vagina and extending from the bases of the parametrium to the attachment 
between the vagina and the 
bladder, rectum, and levator 
ani fascia is designated the 
paracolpium. The cellular 
tissue between the folds of 
the uterovesical ligaments 
and the cervix and the supe- 
rior surface of the bladder is 
termed the paracystium. 
Radiating from the neigh- 
borhood of the internal os 
there is combined with the 
cellular tissue more or less 
well-defined nbro-muscular 
and elastic bands. These 
serve as a part of the sup- 
porting apparatus of the 
pelvic viscera reinforcing the 
broad, uterosacral and utero- 
vesical ligaments. At the 
base of the broad ligaments 
they comprise what are 
known as the cardinal liga- 
m e n t s — posteriorly they 
form the supporting tissue 
of the uterosacral ligaments, 
and anteriorly they give 
strength to the uterovesical 
ligaments. The most im- 
portant vascular channels that supply the pelvic viscera pass through 
and are supported and sheathed by extensions and prolongations of this 
cellular and connective tissue (Fig. 62). The lymphatic channels from the 
uterus, especially those from the cervix and from the upper part of the 
vagina and the base of the bladder, course through this tissue on their 
way to the pelvic lymph-glands. From its position and from the lymphatics and 
the venous channels carried by it, this tissue is exposed to traumatism and to in- 
fection. Cellulitis may occur as the result of either condition, but is more com- 
monly due to infection. 
4 




Fig. 61. — Frontal section of pelvis through urogenital triangle, 
showing muscles, fascia and cellular connective tissue, c.t. con- 
nective tissue; b.v., vestibular bulb; b.c, bulbo-cavernosus muscle; 
l.m., labium minus; f.o.i., fascia of the obturator internus; o.i., 
obturator internus; p.f., pelvic fascia; La., levator ani muscle; t.p., 
transversus perinei muscle (semi-schematic); fi., superficial fascia 
of urogenital triangle; c.c, crus clitoris; i.e., ischio-cavernosus 
muscle; u., ureter. 



50 



GYNECOLOGY 

THE PELVIC FLOOR 



The pelvic floor is formed by three muscles — the levator ani, coccygeus, 
and pyriformis — and their corresponding fascia (Figs. 63, 64 and 65). The 
most important of these muscles is the levator ani. This muscle arises from 
the posterior surface of the body of the os pubis in front, from the spine 
of the ischium behind, and between these two points, from the white line that 
marks the division of the pelvic fascia into the obturator and the recto- 
vesical fascia. Its fibers converge downward and toward the median line, to 




Fig. 62. — Semi-diagrammatic picture showing same general course of arteries, veins and lymph- 
atics: (A) ovarian artery and vein, with lymphatics draining ovary and fundus which empty into 
lateral lumbar nodes; (B) uterine artery and vein with accompanying lymphatics which drain the 
lower uterine body, cervix and upper part of the vagina and empty into the median iliac nodes; 
(C) artery and vein of round ligament with accompanying lymphatics, which drain the fundus and 
empty into inguinal nodes; (D) vaginal artery and vein with accompanying lymphatics which 
drain vagina and empty into hypogastric nodes near origin of uterine artery; (E) branches of 
internal pudic artery and vein which supply the vaginal orifice, with accompanying lymphatics 
which drain the vaginal orifice and empty into the inguinal nodes. 

be inserted into the coccyx, in the form of a tendinous raphe extending be- 
tween the coccyx, the anus, and the lower part of the rectum. 

The coccygeus muscle lies immediately posterior to the levator ani, and is 
comparatively small in size. It arises from the spine of the ischium, and is 
inserted into the sides of the sacrum and the coccyx. 

The pyriformis muscle lies posterior to the coccygeus. It arises from the 
anterior surface of the sacrum, passes through the corresponding great 
sciatic foramen, and is inserted into the summit of the great trochanter. 

The pelvic diaphragm or floor is attached directly to the lower part of 



ANATOMY OF THE GENERATIVE ORGANS 



51 





Fig. 63. — Fascia of pelvic floor. 



Crus clitoris 



Fascia lata 
Branch of perineal 
artery to bulbs and 
clitoris 
Superficial transver- 
sa perinsei muscle 
Superficial perineal 
artery at its origin 
from the internal 
pudic 
Ischio-rectal fossa 

Inferior hemor- 
rhoidal artery 



Gluteus maximus 
muscle 




Clitoris 



External urethral 

orifice 

Erector clitoris 

muscle 

Constrictor vaginas 

muscle 

Bulbo-cavernosus 

muscle 

Deep transversus 

perinari muscle 

Sphincter ani 

muscle 

Tuber ischii 

Levator ani muscle 



Perineal nerve 



FlG. 64. — External muscles, fascia and structures of the perineum. 



52 



GYNECOLOGY 



the rectum, its anterior fibers being in close relation to the vaginal sulci. 
The attachment to the lower rectum is. by actual blending of the levator 
libers with those of the intestine. It is connected with the vagina chierly by 
fascial attachments, particularly by those relating to the superior layer of 
the triangular ligament I Fig. 66 > . and by virtue of certain accessory muscles — 
the transversus perinaei and the constrictor vaginae — supporting the lower 
vagina and the external genitalia. 

The transt ersus periiuei muscles are made up of superficial and deep divi- 
sions. They arise on either side from the inferior ramus and tuberosity ot 




M^LKki 




'..i. levsrrr 



the ischium, and pass to the median line, where they unite with each other 
and with the central tendinous point of the perineal body. The bitlbocc: 
nosus, or constrictor ragince muscle, arises from the central tendon of the 
perineum ; it encircles the vaginal orifice, investing the vestibular bulbs, 
and is lost in the fascia about the clitoris. The external and internal sphi> 
muscles of the anus (spkmcte are intimately related to the levator ani 

and the central tendinous point of the perineum. The external sphincter 
muscle arises from the tip of the coccyx and the tendinous raphe, extend- 
ing between the coccyx and the anus. The libers encircle the anus — the 
superficial ones being in close relation with the skin — and are inserted into 
the central tendon of the perineum and the superficial fascia. Some of the 
libers decussate with the sphincter vaginae. The internal sphincter ani is 



ANATOMY OF THE GENERATIVE ORGANS 



53 



composed of involuntary muscle bundles, and is a thickening of the circular 
layer of the lower end of the rectum. It encircles the beginning of the anal 
canal. It is about 4 mm. thick and extends for a distance of from 2.5 to 3 cm. 

THE FASCIA OF THE PELVIC FLOOR 

The arrangement of the fascia of the pelvic floor is of considerable im- 
portance, because of the part it plays in the reenforcement and support of 
the muscles that form the pelvic diaphragm. The superficial fascia of the 
perineum is continuous anteriorly with that of the lower abdominal wall, 
and, like the latter, is composed of two layers. The superficial layer is in 
reality merely the panniculus adiposis of the skin. The deeper layer, known 




Fig. 66. — The triangular ligament in the female: (Ir.) triangular liga- 
ment; {pp.) window cut out, showing the deep transversus perinasi 
muscle. 

as Colles' fascia, is membranous in character and devoid of fat. It is con- 
tinuous in front with the deep layer of the superficial fascia of the abdominal 
wall ; laterally, it is attached to the sides of the pubic rami and the ischia, 
and posteriorly it blends with the posterior border of the triangular liga- 
ment along the lower margin of the superficial transversus perinsei muscles. 
Behind this line it unites with the superficial layer in a single sheet that becomes 
continuous with the superficial fascia of the gluteal region. The deep fascia 
of the perineum forms what is known as the triangular ligament. This is 
composed of tivo layers — a superior and an inferior. Each layer is attached 
in front to the corresponding rim of the pubes, and laterally to the corre- 
sponding edge of the ramus of the pubis and ischium. Behind, on an 
imaginary line drawn transversely between the tuber ischii, the two layers 
unite with each other and with the deep layer of the superficial fascia. The 



54 



GYNECOLOGY 



triangular ligament is perforated by the vagina and the urethra. Its superior 
layer fuses above with the vesical reflection of the rectovesical fascia (pubo- 
vesico-cervical ligaments), below with the levator fascia, whereas at the 
sides both layers are continuous with the obturator fascia (Fig. 67). 

THE BLOOD-VESSELS OF THE GENERATIVE ORGANS 

The pelvic organs and the external genitalia receive their blood supplv 
chiefly from the ovarian, the uterine, the vesical, the hemorrhoidal, and the 



Femoral ring 
Femoral artery and vein 



Gimbernat's ligament 

Space for blood-vessels 

Ligament ilio-pectineum 
Space for muscles 



Pelvic 




fascia 


\ 
\ 
\ 


Femoral 




nerve 


1 




Poupart's 
y^ ligament 



Fig. 67. — The pelvic diaphragm from above. The pelvic fascia on the right side has been removed: (v) vagina; 
(r) rectum; (P) promontory of sacrum; (a) pubococcygeus division of levator ani muscle; (b) ilio-coccygeus 
division of levator ani muscle; (c) ischio-coccygeus division of levator ani muscle; (d) ligament tubero-sacralis; 
(e) ligament spinoso sacralis; (/) ischiatic foramen, large and small; (o) obturator internus muscle; (a.t) 
arcus tendineus (white line) ; (f.o) obturator foramen. 



internal pudic arteries. Most of these vessels are derived from the ramifi- 
cations or the divisions of the internal iliac. The only arteries of impor- 
tance that arise from sources other than the internal iliac are the ovarian, 
which spring from the abdominal aorta, and the superior hemorrhoidal 
artery, which is derived from the inferior mesenteric (Fig. 68). 

Arteries. — The ovarian arteries are the analogue of the spermatic arteries 
in the male. They have their origin in the anterior surface of the aorta, a 



ANATOMY OF THE GENERATIVE ORGANS 



55 



little below the renal arteries. They run beneath the peritoneum to the 
pelvic brim, where they cross the common iliac vessels and enter the broad 
ligament at the pelvic attachment. They pass between the layers of the 



Right ovarian 

vein, 

B. Right ovarian" 
artery 



Left ovarian artery 
Left ovarian vein 



Inferior mesenteric 
arterv 



Superior hem- 
orrhoidal artery 



Right uterine 
artery 

Right internal 
pudic artery 
Right inferior hem- 
orrhoidal artery 
Vaginal branch 
from inferior 
vesical artery 
Artery to clitoris 

Artery to bulb 




Median sacral 
artery and vein 



Left uterine vein 



— Vein from rectum 



Deep vein from 
clitoris and vein 
from vestibular 
bulb 



Fig. 68. — The blood supply of the pelvic viscera. 

broad ligament to the cornua of the uterus, sending branches to the Fallopian 
tube, and anastomosing with the corresponding uterine artery beneath the 
isthmus of the tube. 



56 



GYNECOLOGY 



The internal iliac artery, also called the hypogastric artery, is, as its name 
implies, the internal terminal division of the common iliac. Its most impor- 
tant branch is the uterine artery, but the superior and inferior vesical, the 
vaginal, the obturator, and the middle hemorrhoidal vessels are also derived 
from it. The main stem divides into the internal pudic and sciatic arteries. 
The uterine artery runs through the base of the broad ligament toward the 
neck of the uterus. At a point about 2 cm. from the cervix it crosses the 
ureter (Fig. 69), and there turns upward and courses between the layers of the 

broad ligament to the side of the 
uterus. At the cornua it anasto- 
moses with the corresponding 
ovarian artery. From the anas- 
tomosis a branch is given off to 
the round ligament. 

The superior vesical artery sup- 
plies the upper and middle portions 
of the bladder; whereas the inferior 
vesical artery supplies the base and 
neck of the bladder. 

The vaginal arteries run to the 
sides of the vagina. Each vessel 
divides into numerous branches 
that anastomose w r ith the corre- 
sponding branches ot the opposite 
side. Along the median line of 
both the anterior and the pos- 
terior surface of the vagina a 
vessel, known as the azygous 
artery of the vagina, is more or 
less constantly present. 

The superior hemorrhoidal 
artery is the terminal portion of the 
inferior mesenteric, and descends 
between the layers of the pelvic 
mesocolon. The middle hemorrhoi- 
dal artery arises from the internal 
iliac, the inferior vesical, or the inter- 
nal pudic. The inferior hemorrhoidal artery arises from the internal pudic. 

The internal pudic artery passes through the lesser sacrosciatic notch to the 
ischiorectal fossa. It give's off the inferior hemorrhoidal, the superficial 
perineal artery, the artery of the bulbs, and the urethral artery, and ends in 
the dorsal artery of the clitoris. 

Veins. — The ovarian veins arise from the hilum of the ovary and anasto- 
mose w r ith the veins of the uterine fundus, Fallopian tube, and round liga- 
ment, forming what is known as the pampiniform plexus. This plexus lies 
with the ovarian artery between the layers of the broad ligament ; it merges 
into a single trunk which ascends along the course of the ovarian artery into 
the abdominal cavity. The right vein empties into the inferior vena cava; 
the left into the left renal vein. 




Fig. 69. — Anatomy of ureter, showing its course in the 
pelvis and its intimate relation to the uterine artery. 
The fundus of the uterus has been bisected and lifted 
away at its junction with the cervix. (After Tandler 
and Halban.) 



ANATOMY OF THE GENERATIVE ORGANS 



57 



The uterine vein takes its origin at a point opposite the external os. It is 
derived from the plexus uterovaginalis. At first it is double, both trunks 
following the course of the artery. Beyond the ureter the two become 
united, and the vessel empties into the internal iliac. 

The vesical veins originate in the vesicovaginal plexus. They empty 
into the internal iliac. 




Pig. 70. — Sagittal section of rectum, showing hemorrhoidal arteries, veins, and 
lymphatics of rectum and anus. Superior hemorrhoidal artery comes fromthe 
inferior mesenteric. Middle hemorrhoidal artery comes from internal iliac 
artery. Inferior hemorrhoidal artery comes from internal pudic artery. Supe- 
rior hemorrhoidal vein empties into the portal system through the inferior 
mesenteric vein. Middle hemorrhoidal vein empties into the inferior caval 
system through the internal iliac vein; it forms by its connections a communi- 
cation between portal and inferior caval systems. Inferior hemorrhoidal 
vein empties into the internal pudic vein. The lymphatics of the upper two- 
thirds of the rectum drain into the sacral glands on the front of the sacrum. 
The plexus around the anus and lower part of the rectum drains into the 
inguinal glands. 



The internal pudic vein enters the pelvis through the lower part of the 
great sacrosciatic foramen, and empties into the internal iliac. 

The internal iliac or hypogastric vein accompanies the internal iliac artery, 
lying to its inner and posterior aspect. At the level of the sacroiliac syn- 
chondrosis it unites with the external iliac to form the common iliac vein. 

The obturator vein accompanies the obturator artery and, as a rule, empties 
into the internal iliac. 

The superior hemorrhoidal vein originates in the hemorrhoidal plexus, and 



58 



GYNECOLOGY 



unites with the sigmoid veins to form the inferior mesenteric. It communicates 
with the middle and inferior hemorrhoidal veins, thus placing the portal 
and inferior caval systems in communication. 

The middle hemorrhoidal vein arises from the hemorrhoidal plexus and 
empties into the internal iliac or one of its tributaries. 

The hemorrhoidal plexus encircles the rectum. It is composed of two 
venous networks — the internal hemorrhoidal plexus in the submucosa of the 
rectum, and the external hemorrhoidal plexus on the outer surface of the 



Vena cava 
Aorta 



Common iliac artery 
Common iliac vein' 
Ilio-lumbar artery 
(abnormally large) £ 
Internal iliac artery- 
External iliac artery 
External iliac vein s 



Obturator ■ 
artery, vein 
and nerves- 
Deep circum-* 
flex iliac artery""" 
Round, \ 
ligament 
Deep 
epigastric""' 
artery 




--•Gluteal artery 
• "Lateral sacral artery 
.--Median sacral artery 
Hypogastric artery 

^-Sciatic artery 

Internal pudic 
artery 

Middle hemor- 
rhoidal artery 
and vein 



Fig. 71. — Blood-vessels of the pelvis: (s) branches of superior vesical artery; (v) vaginal branch from inferior 
vesical artery; («) superior vesical artery merging with obliterated remains of hypogastric arteries; (i) inferior 

vesical artery; (ut) uterine artery. 

rectum. The inferior hemorrhoidal veins pass from the region of the anus 
through the ischiorectal space and empty into the internal oudic vein 
(Figs. 70 and 71). 

THE LYMPHATICS OF THE PELVIS 

The pelvic lymph-nodes are arranged along the course of the principal 
vessels, and for convenience may be divided into three groups : The iliac, 
the hypogastric, and the sacral. 

The iliac nodes lie along the course of the common and external iliac vessels, 
from Poupart's ligament to the bifurcation of the aorta. They receive after- 



ANATOMY OF THE GENERATIVE ORGANS 



59 



ent lymphatic vessels from the epigastric and circumflex iliac nodes, from 
the lower part of the ureter, bladder, cervicovaginal junction, clitoris, etc. 
They distribute efferent vessels to the lower lateral lumbar nodes. 

The internal iliac or hypogastric nodes are situated on the lateral walls of the 
pelvis, along the internal iliac vessel and its branches. They receive afferent 
vessels from all the pelvic organs supplied by the internal iliac artery or its 
branches. They send lymphatic vessels to the iliac nodes on the promon- 
tory of the sacrum. 




Sacral glands - -Of 



Iliac glands ?fgH 



Fig. 72. — Lymph vessels and glands of pelvic and lumbar regions, showing course of uterine lymph vessels 
to iliac, sacral and lumbar glands, the course of lymph vessels from fundus and round ligaments to the in- 
guinal glands, and the course of lymph vessels of the ovary to the lumbar glands. (After Poirier and Sabotta) 



The sacral nodes lie on the ventral surface of the sacrum, along the middle 
sacral vessels and lateral sacral arteries. They receive afferent vessels from 
the cervix by way of the uterosacral ligaments from the neighboring 
muscles, and from the sacrum, and they send vessels to the iliac nodes on 
the promontory of the sacrum. 

The inguinal nodes are really a single group, situated in the inguinal region 
over Scarpa's triangle, where they form a mass of considerable size. The 



60 GYNECOLOGY 

upper nodes are termed the inguinal, whereas the lower are called the sub- 
inguinal. 

The lymphatics from the external genitalia pass to the inguinal or sub- 
inguinal nodes ; those from the clitoris may reach the lower iliac nodes. 

The lymphatics of the ovary and Fallopian tube follow the course of the 
ovarian blood-vessels and terminate in the lateral lumbar nodes. 

For convenience of description, the .lymphatics of the uterus may be 
divided into three groups : 

(i) The large fiuidal, which follow the ovarian lymphatics and terminate 
in the lumbar nodes. 

(2) The small fundal, which reach the inguinal nodes along the 
round ligament. 

(3) The lower corporeal and cervical. These pass laterally along the uterine 
vessels to the iliac nodes, in the angle between the external and the internal 
iliac arteries. Posteriorly, branches run through the uterosacral ligaments 
to one uterosacral gland. 

The lymphatics of the vagina are divided into three groups: 
( 1) The lymphatics from the upper part, which terminate in the median 
iliac nodes. 

(2) The lymphatics from the middle part, terminating in the hypo- 
gastric nodes. 

(3) The lymphatics from the lower part, which terminate in the inner 
inguinal nodes (Fig. 72). 

THE ABDOMINAL WALL 

The abdominal wall, or parietes. is made up of muscles and fascia? which 
interlace and form a strong boundary for the abdominal cavity and false 
pelvis. In the median line are the two rectus muscles, running from the 
ensiform cartilage and lower ribs to the symphysis pubis. Beyond the 
rectus are the external and internal oblique and the trans versalis muscles and 
aponeuroses. The aponeuroses of the lateral group connect the fascia of 
the rectus muscles to their outer side in what is known as the linea semi- 
lunaris, which runs from the tip of the ninth costal cartilage to the spine of 
the pubis. The fascia of the rectus surrounds that muscle, except at its lower 
third, where it passes directly in front of it. The point of fascial union in 
the median line is known as the linea alba. The abdominal muscles are 
attached above to the costal margins and the associated musculature ; pos- 
teriorly, to the lumbar group, and below, to the pubes. iliac crests, and to 
the condensation of fasciae of the oblique and transverse muscles known as 
Poupart's and Gimbernat's ligaments. 

BIBLIOGRAPHY 

Huxxer, Lyox : " Mensuration and Capacity of the Female Bladder." J. A. M. A., Dec. 
16, 1899. 

Piersol. G. A. : Human Anatomy. Lippincott. Phila.. 1907. 

Porrier, Cuneo and Delamere : The Lymphatics. Keener & Co.. Chicago. 111.. 1904. 

Sampson : " The Variations in the Blood Supply of the Ovary and Their Possible Opera- 
tive Importance." Trans. Amer. Gyn. Soc, 1916, vol. xli, p. 429. 

Savage: The Surgery, Surgical Pathology and Surgical Anatomy of the Female Pelvic 
Organs. Wm. Wood & Co.. New York. 1880. 

Tuttle, J. P. : Diseases of the Anus, Rectum and Pelvic Colon. Appleton. X. Y., 19,07. 



CHAPTER IV 
PHYSIOLOGY 

Introduction. — The generative organs remain functionless until puberty 
is reached. During the reproductive period, which extends from puberty to 
the menopause, these organs are highly specialized structures whose func- 
tions bear most important relations to the general physiologic activity of 
the individual, and, indeed, to a certain extent dominate it. Following the 
menopause the generative organs again become functionless and undergo 
atrophy. It is a peculiarity of the generative organs that they remain 
dormant up to a certain time, after which they become active for a period of 
years, comprising what is known as the prime of life, and then become extinct. 

Although reproduction may occur at puberty, children born during this 
early period are apt to be frail and weakly. A female is not sexually 
matured — that is, entirely fitted for wifehood and motherhood — until she is 
out of her teens, or even several years later. The stage of sexual maturity 
is known as nubility. 

The Age of Puberty. — Puberty [Latin: puber'tas, maturity], the age at 
which an individual begins to functionate sexually, occurs in women be- 
tween the twelfth and fifteenth year. In hot climates puberty is said to 
occur early, whereas in cold climates it occurs late. Englemann, after an 
analysis of 60,000 cases, declared that the difference in onset is less marked 
than is commonly supposed. The negro maiden of Somaliland sometimes 
matures at sixteen, as late as her Lapland and Samoyed sisters. Eskimo 
women, on the other hand, may become mothers at the age of twelve — just 
as early as Hindu women. Englemann attributes this to the oily diet of the 
arctics and the sluggish habits of the equatorial natives. It is a fact, never- 
theless, that warm climates do predispose to early puberty, and cold climates 
to late puberty ; the variation is more apparent relatively in distant parts of 
the same zone than in extreme zones, such as the tropical and the arctic. 
The onset of puberty is influenced also by race, social oosition, and mode 
of life. 

The effect of race and climate on puberty is illustrated by the observa- 
tion of Das, that Hindu and Mohammedan girls in India menstruate two or 
three years earlier than English girls born in India, and that the latter 
menstruate a year or so earlier than English girls born in England. 

Kisch asserts that girls in the higher planes of society menstruate earlier 
than those in the lower ; that city girls menstruate earlier than country 
girls ; that those of rugged constitution menstruate earlier than those who 
are frail and weakly ; brunettes menstruate earlier than blondes. The 
Hebrew (Semitic) and the oriental races menstruate early, the Aryans and 
the Slavs later. 

Manifestations of Puberty. — The onset of puberty is attended with many 
changes, both psychic and physical. The intellect, emotions, and will of the 
girl gradually become those of the woman. The range of voice is increased 

61 



62 GYNECOLOGY 

by a lengthening of the larynx, and the face and figure acquire the contour 
characteristic of the sex. The internal and the external sexual organs, with 
their accessory structures, increase in size and in vascularity ; the pelvis assumes 
a characteristic shape. The pubic and axillary hairs now make their appear- 
ance. The body or fundus of the uterus develops rapidly, until it constitutes 
two-thirds of the entire organ, whereas the cervix, which is larger than 
the fundus during infantile life, forms but about one-third of the entire 
structure. The infantile twisting of the tubes is gradually eliminated, and 
the tubal canal is somewhat reduced in length. Quite marked changes take 
place in the ovary. Clark has shown that during childhood the primordial 
follicles develop up to a certain point in about the same manner that they do 
after the age of puberty. The follicles affected are those lying in the most 
vascularized part of the young ovary, i.e.,- near the center; they never reach 
the surface and do not rupture. After attaining a fair size the granulosa 
cells degenerate, and the follicle is finally obliterated by a process that 
resembles the evolution in older ovaries of the corpus luteum and the corpus 
albicans. Nearly every vestige of the latter is absorbed, but the destruction 
of the follicles at the center of the ovary gradually causes an increase of 
connective tissue at this point, and at the age of puberty the undeveloped 
primordial follicles are in the cortex of the organ, and as the Graafian follicles 
reach their full growth, they distend the tunica albuginea and rupture. 

FUNCTIONS OF THE SEXUAL ORGANS 

The External Genitalia. — The labia protect the orifice of the vagina 
and the urethra ; the clitoris and the vestibular bulbs are erectile structures 
concerned with copulation. 

The Vagina. — The vagina is penetrated by the male organ during copu- 
lation. The vaginal fornices are the receptacle for the spermatic fluid, 
whence the spermatozoa gain access to the uterus. The vagina is also the 
passageway through which the foetus is born. Owing to its shape, which re- 
sembles the letter H, and to the reserve mucosa in its sulci, the vagina is 
capable of undergoing marked distention without serious injury during labor. 

The Uterus. — The uterus secretes the menstrual fluid. During preg- 
nancy the uterus nourishes and protects the ovum. The activity of the 
uterine muscle is one of the most important factors in the process of labor. 

The Fallopian Tubes. — The tubes transmit the ova to the interior of the 
uterus. They are a lurking place for the spermatic particles, and concep- 
tion is believed usually to occur in their outer third. Under exceptional cir- 
cumstances they may give off a bloody discharge during menstruation, but, 
as a rule, they take no part in the process. 

The Ovaries. — The ovaries are the dominating reproductive organs, and 
are responsible for the physiologic activity of the remaining organs. If the 
ovaries are healthy and active, the other organs are likely to be the same ; if 
the ovaries are poorly developed and functionally deficient, almost any 
abnormality in development may be found in the other organs. This may 
be somewhat in the nature of cause and effect, or the condition of the entire 
genital system may be primarily hypoplastic. 

It has long been the belief that the ovaries possessed an internal secre- 



PHYSIOLOGY 63 

tion, and since the experimental work of Fraenkel the corpus luteum is recog- 
nized as the most actively secreting- portion. The follicles of the ovary and 
the interstitial gland also possess a secretion. This combined internal 
secretion of the ovary has a general effect upon the economy, which con- 
tributes to the well-being of the individual. 1 The truth of this statement is 
apparent from the numerous vasomotor and nervous disturbances that at 
times follow abrupt withdrawal of the secretion, as after bilateral oophorec- 
tomy (artificial menopause). The ovarian secretion brings about the 
phenomena of menstruation (see Ovulation), and on its withdrawal 
menstruation ceases. 

The ovarian secretion is also responsible for the formation of the decidua 
and the early enlargement of the uterus during pregnancy ; in other words, 
it aids in the nourishment and protection of the early ovum. Fraenkel has 
demonstrated the truth of these statements in experiments on rabbits. De- 
struction of the corpora lutea in both ovaries w r as followed by cessation of 
menstruation for a period of from one to two months ; destruction of the 
corpora lutea in the earliest stage of pregnancy resulted in degeneration of 
the embryo. The internal secretion of the ovary is the one stimulant 2 that 
is essential to the physiologic activity of the reproductive organs. Some of 
the other ductless glands also have an influence upon menstruation, and 
their secretion probably serves as an adjuvant to the ovarian products. 
The influence which these glands have upon the reproductive system may 
be learned from a study of the following structures : 

The Pituitary Body. — A definite relationship has been established be- 
tween the pituitary body and the generative organs. It may be stated in a 
general way that the hypophyseal secretion is antagonistically comple- 
mentary to that of the ovaries. The most frequently encountered mani- 
festation of a dysfunction of the pituitary body is evidenced in that symptom- 
complex resulting from a hypofunction after puberty, consisting of a marked 
adiposity, associated with genital atrophy and a lack of or diminution in the 
functioning of the genital organs. The early increase in genital activity in 
acromegaly, due to hyperfunction, is soon followed by a functional atrophy 
of the genital organs. That the gland is enlarged in pregnancy has been 

1 Frank notes the secreting parts of the ovaries as the follicles, the corpus luteum, 
and the interstitial gland. The ovarian secretion is not essential to the continuance of 
life. Hyperfunction of the ovaries in adults produces menorrhagia ; hyperfunction in 
children gives rise to premature sexual development. Hypofunction in adults causes 
amenorrhoea and obesity ; in children it produces infantilism. Oophorectomy in adults is 
followed by an artificial menopause ; in children, by eunuchoid habits, genital atrophy, and 
a neuter type of development (no data bearing on the findings in humans are available). 
The reports on the therapeutic use of ovarian extracts show no uniformity of results. 

2 There are a few well-authenticated reports of a continuance of menstruation after 
complete removal of both ovaries. This has led some observers to believe that the 
compensatory activity of some of the other glands of internal secretion normally 
associated with the ovary in the production of menstruation may be sufficient to con- 
tinue " the habit of menstruation," especially if, by reason of uterine adhesions, the 
blood supply to the uterus is above normal. While this possibility cannot be denied 
absolutely, the continuance of the menses in these cases is more probably due to the 
presence of supernumerary ovaries that have escaped observation. 

There are two varieties of supernumerary ovaries : First, contiguous supernumerary 
ovaries, which are situated on or close to the normal ovary ; secondly, aberrant ovaries, 
which lie at a point in the line of descent of the fcetal ovary (these are the size of a 
millet seed, a pea, or rarely of a cherry). 



64 GYNECOLOGY 

shown by necropsy findings in women who have died during pregnancy, as 
well as by the facial changes, simulating those of acromegaly, that are prone 
to occur during pregnancy. The increase in the anterior lobe occasioned 
by pregnancy may persist for several years. Removal of the pituitary gland 
in pregnant dogs has been followed by abortion. 

Extracts of the posterior lobe have been used as oxytocics during par- 
turition and for the control of uterine hemorrhages in the non-pregnant 
state. Extracts of the anterior lobe have been used with some success in 
functional amenorrhcea associated with marked adiposity. 

The Thyroid Gland. — The most prominent symptom of the inter-rela- 
tionship of the genital organs and the thyroid gland consists in the marked 
enlargement of the gland that occurs during pregnancy. This increase in 
the size of the gland, with its correspondingly greater amount of secretion, is a 
physiologic hypertrophy, and is believed to assist in the regulation of the 
metabolism of the maternal organism during this period. 

A similar increase in the size of the gland, though of less marked degree, 
is often noted during menstruation. Disturbances of the thyroid gland may 
be responsible for amenorrhcea, menorrhagia, and metrorrhagia. That its 
physiologic relationship to the genital organs is as yet imperfectly under- 
stood is evidenced by the fact that these conditions, while of distinctly oppo- 
site nature, are often benefited clinically by thyroid therapy. Patients 
suffering from Graves' disease are usually sterile, and pregnancy exercises 
a decidedly unfavorable influence on the prognosis of Graves' disease. The 
undeveloped genitalia symptomatic of hypothyroidism, myxcedema, and 
cretinism are often stimulated to growth by the administration of the neces- 
sary thyroid tissue. Many cases of myoma of the uterus are associated with 
hypertrophic thyroid glands. The administration of thyroid gland extract, 
alone or in combination with other glandular substances, is indicated only in a 
few instances, and owing to the fact that an excessive secretion of this gland is 
easily produced, and may and often does cause serious nervous and func- 
tional disturbances, the original dose should be small — one-half grain three 
times a day, the dose gradually increased as may be found necessary. 

The Parathyroid Glands. — From the fact demonstrated experimentally 
in animals, that tetany follows removal of the parathyroid glands, the at- 
tempt has been made to prove that a similar condition in the human may 
be due to an insufficiency of parathyroid tissue. The administration of 
parathyroid glandular tissue in the tetany of pregnancy, eclampsia, and 
osteomalacia has not, however, been sufficiently successful to call for more 
than a brief mention. 

The Suprarenal Glands. — The inter-relationship of the suprarenal glands 
and the ovaries and other genital organs has been manifested in several 
conditions. The suprarenal glands are hypertrophied during menstruation 
and pregnancy in women as well as in animals. Precocious and abnormal 
sexual development is commonly found associated with a marked increase 
in the size of the suprarenal glands ; hypernephromata may be accompanied 
by an abnormal sexual development, even in children. Hyposuprarenalism, 
known clinically as Addison's disease, is often associated with diminished 
genital activity and even organic atrophy. 



PHYSIOLOGY 65 

The Pineal Gland. — The relation of this gland to the physiologic activity 
of the female pelvic organs has been manifested in the pronounced over- 
development of the sexual organs before puberty in cases associated with 
tumor formation of the pineal gland. 

The Placenta. — The placenta contains a chemical substance that is 
known to be thermostabile (Frank) (very resistant in strong alkalis and 
acids and completely soluble in 95 per cent, alcohol), and that experimentally 
induces rapidly hyperplasia of the uterus and the breast. In its physical, 
chemical, and biologic properties it appears identical to a similar substance 
obtained from the corpus luteum. In view of this identity it is considered 
probable that the placenta acts merely as a storage reservoir for corpus luteum 
secretion during the latter half of pregnancy. 

The Mammary Glands. — That a close relationship exists between the 
genital organs and the breast is obvious. This is proved by the rapid 
development of the breasts at puberty, the swelling of the breasts at the 
menstrual periods, the hypertrophy of the breasts and secretion of milk 
incident to pregnancy and lactation, and the atrophy that takes place at 
the menopause. 

These changes seem to be brought about by some chemical agent that is 
present in the blood. The derivation of this substance has been ascribed to 
the ovary and the placenta, but no entirely satisfactory solution of the 
problem has as yet been offered. 

MENSTRUATION 

Menstruation [Latin: menstruus, monthly, from mensis, month] is a com- 
plex process of which the most obvious evidence is the menstrual flow. It 
recurs at periodic intervals of about four weeks from puberty to the meno- 
pause. The provocative impulse evidently lies in the ovaries, for if these 
organs are removed, menstruation ceases. The ovary has an internal secre- 
tion that gives rise to the menstrual molimina. An ovarian impulse and a 
uterine response are essential to the menstrual flow. The internal secretion 
of the ovary produces the impulse, and the endometrium excretes the 
menstrual fluid. The menstrual flow is but a part of menstruation. Besides 
its effect on the endometrium, the ovarian secretion, either alone or more 
probably in combination with the other ductless gland secretions, generally 
stimulates metabolism as the menstrual epoch draws near. This exaggeration 
of metabolic activity is recognized by an increase in the function of the muscu- 
lar, respiratory, circulatory, and nervous systems before the flow appears. 
After the flow sets in, there is a relative decrease. There are various sub- 
jective and objective manifestations of the metabolic disturbance; thus the 
patient may complain of lassitude, headache, and pain in the lower part of 
the abdomen, in the back, and in the thighs. The breasts may become 
engorged and painful. There is often some perversion of taste and of the 
other senses. Disturbances of the digestive tract are not uncommon. Vari- 
ous neuroses may become manifest, and spots of pigmentation and skin erup- 
tions may appear upon the face, thighs, abdomen, and breasts. The widest 
variation of these symptoms may obtain, depending upon the temperament 
and the physique of the individual. 
5 



66 GYNECOLOGY 

The Menstrual Fluid. — The menstrual fluid consists of blood mixed with 
the glandular secretions and the desquamated surface epithelium of the 
endometrium. As long as the normal proportion between its constituents 
is preserved, menstrual blood shows no tendency to clot. Bell ascribes 
this fact to a lack of fibrin ferment in the menstrual fluid, and Dienst be- 
lieves that the endometrial cells excrete a substance that inhibits coagula- 
tion. The hemal constituent is derived from the subepithelial capillary 
plexus of the endometrium, largely by diapedesis, partly by minute rup- 
tures in the capillary walls. The blood collects in the superficial part of the 
endometrium, beneath the surface epithelium, through which it finally passes, 
detaching the epithelium here and there and carrying away small portions 
(Fig. 73). The amount of menstrual blood lost at a single period is said to 
be from four to six ounces. The flow continues, on the average, for from 
three to five days, but it may vary between one and eight days. 

The Menstrual Habit. — So far as regularity, duration, and amount of the 
menstrual flow are concerned, a woman may exhibit certain peculiarities that 
are compatible with perfect health. Thus the menstrual interval may vary 
between three weeks and a full calendar month, the length of the period may 
be longer or shorter, and the amount of fluid lost may be more or less than 
the average. The individual's custom in this respect is known as her 
menstrual habit. This habit must always be taken into account when estimat- 
ing the significance of the menstrual symptoms. Menstruation does not 
always appear as a well-established function from the start. After its first 
appearance, several months or even a year or more may elapse before men- 
struation becomes periodic and regular. 

Ovulation. — Ovulation is believed by most observers to be coincident 
with menstruation. Thus Clark, in his brilliant work on the circulation of 
the ovary, gave it as his opinion that the increase in the amount of blood 
sent to the pelvic organs during menstruation caused a marked augmenta- 
tion of the intracapsular pressure of the ovary and directly resulted in the 
bursting of the Graaffian follicle. The more recently expressed views of 
Fraenkel, Peters, Schroder, Meyer-Ruge, and others are not in accord with 
those generally accepted in the past. By comparing the menstrual history, 
the histologic appearance of the endometrium (Figs. 73-77), and the results 
of gross and microscopic examination of ovaries removed at operation, these 
investigators conclude that ovulation commonly takes place from fourteen 
to sixteen days after the onset of menstruation. The corpus luteum which 
follows reaches the height of development from the eighteenth to the 
twenty-fifth day, and forms the stimulus for the next menstrual epoch 
(Fig. 78). Should conception occur, then the action of the corpus luteum is 
diverted to the formation of the decidua and the implantation of the ovum. 

Whether or not we accept the newer view, it has always been admitted 
that menstruation and ovulation do not necessarily occur at the same time. 
Thus, Leopold and Mironofr", who were adherents of the older theory, on 
examination of forty-two menstruating women at operation or at autopsy, 
found that ovulation had taken place in only thirty. Arnold made observa- 
tions of a similar nature, and in but thirty-nine out of fifty-four operative or 
post-mortem cases did he find a fresh corpus luteum at the close of the 



PHYSIOLOGY 



67 



menstrual period. Ovulation may occur in women who have had no men- 
strual flow. Thus ovulation continues after hysterectomy with retention 
of the ovaries, when there is not sufficient uterine mucosa to respond to the 






m 



-&&\ 




Fig. 73 



Fig. 74 



m. 



t-mm 



Fig. 75 



I 



.- SI 



Fig. 76 



Figs. 73, 74, 75, 76. — The mucous membrane of the uterus in the various phases of menstruation. 
Fig. 73. — Menstrual mucous membrane one day after menstruation. Fig. 74. — Endometrium during 
the interval. Fig. 75. — Premenstrual condition. Fig. 76. — Third day of menstruation, showing exfolia- 
tion of the superficial layer. (After Hitschmann and Adler, from Keibel and Mall.) 

ovarian impulse. A curious instance of ovulation in the absence of menstrua- 
tion is reported by Stengel. In this case pregnancy and childbirth occurred 
in a woman aged twenty-one who had never menstruated. The woman was 
in robust health, and had been married three years when conception took 



68 



GYNECOLOGY 



place. As a further example it may be noted that pregnancy frequently 
occurs during lactation when the periods have been entirely absent. Geb- 
hard cites a case of Kronig's in which, four days after labor, conception 
again occurred. It is evident, therefore, that while, as a rule, menstruation 








$c 





Fig. 77. — The uterine mucous membrane in the first day of menstruation: (H) hema- 
toma under the epithelium; (Bl) hemorrhage into the compacta; {Co) compacta; 
(Sp) spongiosa; (Po) gland of the post-menstrual type; (Pr) gland of the pre- 
menstrual type; (M) muscularis. Hitschmann and Adler, from Keibel and Mall.) 

and ovulation bear a certain time relation to each other, ovulation may take 
place without menstruation. Menstruation may occur at a different time 
than ovulation, but it is, nevertheless, dependent upon the activity of the 
ovary, for unless follicle-bearing tissue is present in the ovary, menstruation 
will not take place. Clark has shown that menstruation begins at the time 



PHYSIOLOGY 



69 







B 



the Graafian follicles have reached that stage in their development when 
they approach the surface of the ovary and rupture into the free peri- 
toneal cavity. When but few follicles remain and the organ is little more 
than a mass of scar tissue, menstruation ceases. 

The menstrual flow is dependent immediately upon an intense conges- 
tion of the uterine mucosa and a menstrual diapedesis (Fig. 79). The flow is 
modified by abnormalities both in the uterus and in the ovaries. If the 
uterus is imperfectly devel- 
oped, the diapedesis will be 
affected correspondingly. If 
the ovarian tissue is not nor- 
mal, the physiologic impulses 
of menstruation will be faulty 
and the process be variously 
modified. The ill-developed, 
atrophic, or infantile uterus 
excretes less menstrual blood 
than the larger normal organ, 
since its endometrial surface is 
smaller and its blood supply 
deficient. The enlarged uterus 
of chronic metritis or of sub- 
involution gives off more men- 
strual blood than is normal for 
the area of endometrium and 
the blood supply is increased. 
Deficient ovarian secretion 
leads to subnormal menstrual 
congestion and diminished 
menstrual flow. Congenital 
deficiency of the ovarian ac- 
tivity is commonly associated 
with ill-developed uteri. Ac- 
quired deficiency the result of 
resection of the ovaries or of } 
loss of one ovary may be fol- 
lowed by a diminution in the 
menstrual flow, since the men- 
strual impulse has been reduced. Abnormal production of the ovarian 
secretion (as in the presence of Graafian follicle cysts, corpus luteum 
cysts, cystic degeneration) may lead to irregularity, temporary cessation, 
diminution, or increase of the menstrual flow. A perverted ovarian func- 
tion has at times been attributed to nervous influences. According to 
Clark's original theory, the congestion of the ovary at the menstrual 
period, with the consequent increase of tension within the ovary, 
leads to bursting of the ripe follicle projecting from the surface. If the 
more recently expressed views as to the time of ovulation are correct, the 
follicular rupture may be attributed to an increasing accumulation of 
follicular fluid. 





-Schematic drawings to illustrate relation between ovu- 
lation and menstruation: (A) about 21 days after beginning of 
last period: ovulation taking place — mucosa resting; (B) be- 
ginning of new menstrual period: corpus luteum of menstrua- 
tion formed, menstrual endometrium. 



70 



GYNECOLOGY 



4;\^\\\vlY\\vkv 



* ° 
o 



Anatomic Changes Incident to Ovulation and Menstruation. — According 
to Clark, the mature follicle about to rupture appears in the form of a bleb 
projecting from the stroma of the ovary above the level of the tunica 
fibrosa. At the point where this blister rises from the surface of the ovary 
many deeply injected vessels are seen springing from the depths of the 
ovarian stroma, and spreading out over the follicle as a fine net. These 
vessels, as a rule, become less numerous as the most prominent point is 
reached, where they may disappear entirely. It is at this latter point that 
the follicle ruptures, and the ovum with the follicular fluid escapes into the 
pelvis. Following rupture there is an extravasation of blood into the follicu- 
lar cavity. Into this blood-clot newly-formed veins and arteries are pro- 
jected from the connective tissue surrounding the follicle. The granulosa 
cells lining the follicle hypertrophy as the vascular loops are projected in- 
ward, and within the loops of the latter are 
carried toward the center, forming the lutein cells 
(corpus luteum, "yellow body"). When the 
cavity is completely filled in, the lutein cells ap- 
pear large and well nourished, rich in protoplasm, 
with large, oval, prominent nuclei. The lutein 
cells serve as supporting structures until perma- 
nent connective tissue from the periphery is 
produced. 

With the progressive proliferation of the new 
connective tissue the cells of the corpus luteum 
show evidence of fatty degeneration and undergo 
atrophy. The entire follicle gradually becomes 
filled with new connective tissue, forming the 
Su\iq\\Vi\\6V " uxexvxvB v)a\\ corpus albicans, which later undergoes hyaline 
fcatfxWax^ changes and is finally absorbed either in whole 

vv«-xvx& or j n p ar £ After its escape from the follicle the 

Fig. 79. — Schematic drawing to show ... . . . 

the collection of blood beneath the OVUm lies in Contact With the COntlgUOUS SUr- 

StaS^te^tSriZS^ faces of the pelvic peritoneum, Fallopian tube, 

intestine, omentum, or ovary. Just what posi- 
tion the ovum occupies primarily is dependent on chance and is of no 
consequence. It floats in the capillary layer of peritoneal fluid between these 
structures, and is ultimately swept into the fimbriated extremity of the 
corresponding tube by the current produced by the action of the cilia. It 
has been demonstrated that minute foreign bodies in the peritoneal cavity 
are ultimately carried into the Fallopian tubes by the ciliary current. Occa- 
sionally the ovum of one side will be carried into the tube of the opposite 
side, a process known as external migration of the ovum ; it is quite likely 
that its occurrence under normal conditions is not infrequent — it must take 
place in cases of pregnancy following removal of the ovary of one side and 
of the tube of the other. 

Hitschmann and Adler have recently shown that periodic and regu- 
larly recurring anatomic changes in the mucous membrane of the uterus 
take place from one menstrual cycle to the next. 

In the premenstrual stage (Fig. 75) the structure of the endometrium 




\F 



■5 



PHYSIOLOGY 



71 



Dr.l. 



more or less resembles a beginning formation of decidua; the superficial 
capillaries are engorged, the stroma is oedematous, the glands are enlarged, 
with swollen epithelium and diminished lumina. This period lasts from six 
to seven days. 

The second cycle is the menstrual one (Figs. 73 and 76). The stage of 
secretion and hemorrhage lasts from four to six days, during which the 
glands discharge secretion, the superficial areas of the endometrium are 
infiltrated with blood, the superficial 

epithelium is detached, or the cells : g|g 

are separated in certain places per- _ _, --it .*•/■'.. ' ■'• 

mitting the menstrual blood to /$%>- V "' ^'^^■ 

escape. 

The third stage is the post-men- 
strual one (Fig. 74). In this stage 
the epithelial surface is repaired by 
the proliferation of cells, the blood- 
vessels shrink, and the stroma cells 
lose their oedematous character. 

Fecundation. — T h e spermatic Comp 
particles are capable, by their own 
activity, of making their way in the 
uterine cavity and the tubes at the 
rate of 1 cm. in three minutes. It is 
possible that their entrance into the 
uterus is facilitated by reflex move- 
ments of the organ at the time of 
emission. In some of the lower ani- 
mals it has been observed that at 
this time the uterus descends into 
the vagina, the endorrietrial cavity 
becomes reduced in size, and the 
plug of cervical mucus is partly ex- 
pressed from the external os. Im- 
mediately after the orgasm the 
uterus resumes its previous condi- 
tion, during which process it aspirates 
into the uterine cavity a portion of the 
spermatic fluid that has combined with 
the cervical mucus, the alkaline 
cervical mucus possessing a certain attraction for the spermatic particles. 
That this is the process that occurs in the human cannot be asserted posi- 
tively, but it is not unlikely that such an occurrence takes place following 
the orgasm in the female. From the uterine cavity the spermatozoa, by their 
own motility, make their way to the outer third of the tube, where they 
lie in wait for the ovum. The ovum is fecundated by the penetration of one 
sperm-cell. The fertilized ovum then passes down the tube to the uterus, 
which it is said to reach within from three to seven days. The relation of 
ovulation to the menstrual periods is important in determining the time 



Spong 




Muse 



Dr. 2. 



Fig. 80. — Showing the two layers of the decidua of the 

second month, decidua compaeta and decidua spongiosa. 

(Keibel and Mall.) 



72 



GYNECOLOGY 



when coitus will most probably be followed by conception. If ovulation 
occurs simultaneously with menstruation, it is evident that spermatic par- 
ticles gaining entrance to the uterus and thence to the tubes immediately 
after menstruation will fecundate the recently discharged ovum and that 
pregnancy will date from the first coitus following the last normal menstrual 
period. If the more recently expressed view, that ovulation occurs within 
from fourteen to sixteen days after menstruation is correct, then, although 
the onset of pregnancy must be reckoned from the first day of the last men- 
strual flow, the duration of gestation is evidently shorter by a week than 

the classic period of two 
H j \<-l \ *', * ft' « \^ •.> c c*a (jr-j hundred and eighty days. 

M 




S#^ Y; 



If 

ff/jA ha^ 



married women who 
ave sexual intercourse at 
,/.*/ $M re g u ^ ar intervals it has been 
shown that the tubes com- 
monly contain spermatic 
particles, and that, in con- 
sequence, a slight irregu- 
larity in ovulation may re- 
sult in conception taking 
place at any time during the 
month. This irregularity 
explains the apparent varia- 
tion in the duration of preg- 
nancy that at times occurs. 
Nidation of the Ovum. — 
As soon as fertilization 
occurs, certain changes take 
place in the endometrium; 
these have for their purpose 
suitable nidation and nour- 
ishment of the ovum. The 
endometrium becomes 
transformed into the mem- 
branous structure known as 
the decidua. The stroma 
cells of the endometrium 
become greatly hyper- 
trophied, forming large, 
round, oval, or polygonal 
cells with large, lightly-stained vesicular nuclei — the decidual cells. This 
metamorphosis of the stroma cells occurs chiefly in the superficial 
part of the endometrium, and during the process the glands are crowded 
into the deeper part. The superficial area, composed of the decidual cells, is 
known as the compact layer of the decidua {decidua compacta), whereas the 
deeper area, made up of the distended and hyperplastic glands, is termed the 
spongy layer (decidua spongiosa) (Figs. 80 and 81). 

When the fertilized ovum reaches the uterine cavity it finds the endo- 




Fig. 81. — Showing a gland duct of the decidua compacta of the second 

month, containing secretion, and surrounded by typical decidual cells 

and a few leucocytes. (Keibel and Mall.) 



PHYSIOLOGY 



73 



metrium transformed into a thick, succulent structure that serves admirably 
as a resting-place and as a source of nourishment (Fig. 82). 

The ovum at this time has not progressed beyond the stage of develop- 
ment when the blastodermic vesicle is formed, and does not possess any 
villi. The cells of the outer surface of the vesicle, known as the chorion, 
rapidly proliferate and form large, irregular, multinucleated masses of pro- 
toplasm that have peculiar properties and that serve the double purpose of 
implanting and of nourishing the ovum. These cells, owing to their func- 
tion, are known as trophoblasts, and possibly serve to convey nourishment 
to the ovum by osmosis merely through their contact with the decidua. 

Their most peculiar char- 
acteristic is the corrosive 
action they exert on the 
decidua, eating their way 
into the specialized de- 
cidual tissue. 

After a time, little 
shoots of connective tissue 
from the inner layer of the 
chorion project beneath 
the trophoblastic cells in 
the shape of finger-like 
processes and form the 
rudimentary villi (Figs. 
85 and 86). The tropho- 
blast covering the connec- 
tive-tissue stalks is finally 
transformed into two 
layers of epithelium — an 
inner layer, made up of 
polygonal cells, and 
known as Langhan's layer, 
and an outer layer, made 
up of ribbon-like cells, 
termed the syncytium. As 
a result of the corrosive in- 
fluence of the trophoblast upon the decidua, the ovum penetrates and soon sinks 
into the depths of this structure, as a rule, at the upper part of the uterine cavity. 
As the trophoblast eats its way through the decidual tissue it erodes the 
walls of the capillary vessels along its path and permits blood to escape 
between the contiguous borders of the decidua and the advancing tropho- 
blast. Thus are formed the spaces filled with maternal blood — the earliest 
stage in the formation of the intervillous blood spaces of the future placenta 
(Fig. 87). Here and there a villus does not simply project or float, as it were, 
in the maternal blood, but passes to a more distant area and becomes securely 
embedded within the deeper layer of the decidua. These particular villi 
serve as points of attachment between the ovum and the maternal struc- 
tures, and are known as the " fastening " villi. 




Fig. 



>2. — Semi-schematic drawing to show relative size of imbedded 
early ovum and uterus. 



74 



GYNECOLOGY 














w'o 



PHYSIOLOGY 



75 



In time the chorionic villi become especially well developed in the area 
directly opposite the uterine wall. These villi cover that part of the chorion 
known as the chorion frondosum. This and the area of the decidua with which 
it is in relation {decidua serotina) together ultimately make up the placenta. 

The placental space lies between the chorion frondosum and the decidua 
serotina, and contains maternal blood. The blood is separated from the 
capillaries of the fetal villi by the thin layer of specialized chorionic epithe- 
lium known as the syncytium. The only means of communication between 
the maternal and the foetal blood is by osmosis through the syncytial cells. 
There is also possibly a direct cellular participation of the syncytium in this 
exchange, which is compared by Williams to a similar process that takes 
place in the tubules of the kidney and in other organs. 







Ue.R. 




" _ © © " " '* • e o 

ffge&M 2£S*«VJ f*®2gLi 







\ ^* r* y ' ■« og *%v*«*.« - v '•^••. 



-iSfc 



s \^* 



«V 



' '%£?m&*lr : 






«8 



TV. 



?v* 



*Mw 













J • 6. Tr. Bl. 



Fig. 84. — Summit of the Peters ovum: (Bl) blood lacunae; (Ca) capsularis; (Sc) closing coagulum; (5/) its 

stalk; (Sy) syncytium; (Tr) trophoblast; (Ue) uterine epithelium; (Ue.R) the crumpled border of this;_ (a) 

trophoblast nucleus in the syncytium; (b and c) preparatory stages of the syncytium (wreath-like deposit in 

a blood lacuna.) (From Peters, 1899, Keibel and Mall.) 



PREGNANCY 

During the period of gestation the generative organs undergo a pro- 
nounced hypertrophy. The uterus, which, of course, is the organ most 
affected, increases from 6.5 to 7 cm. in length to 28 to 36 cm. There is an 
increase in capacity of more than 500 times, and an increase in weight of the 
organ of from one ounce to about two pounds (Figs. 88 and 89). The general 
enlargement is due to the increase in the size and in the number of the 
muscle cells, as well as of the blood-vessels, lymphatics, nerves, and elastic 
fibers. During the first half of pregnancy there is an actual hypertrophy of the 
constituents of the uterine wall. After this time the hypertrophic process 
ceases, and the thickened muscular sac bcomes distended. The wall of the 



76 



GYNECOLOGY 



h.-z. 



uterus at term measures about 5 to 7 mm. in diameter. From the very begin- 
ning of pregnancy the hypertrophy of the uterus affects all parts quite equally, 
but as pregnancy advances the fundus is almost exclusively the portion affected 
(Fig. 90). One of the early indications of pregnancy, appearing from the 

sixth to the eighth week, consists in 
an excessive softening of the lower 
uterine segment, so that it may be 
difficult, on bimanual palpation, to 
detect the connection between the 
slightly enlarged cervix and the mark- 
edly hypertrophied and softened 
body. This condition constitutes 
what is known as Hegar's sign (Fig. 
91). Beyond moderate hyper- 
trophy and softening, the cervix 
itself remains unchanged until the 
last month of pregnancy, or even 
until the onset of the first stage of 
labor. The cervical glands secrete 
more actively, and the mucous dis- 
charge is increased. The ovaries do 
not functionate during pregnancy, 
but their vascularity is markedly in- 
creased. The corpus luteum of preg- 
nancy is greatly enlarged and may 

Fig. 85.— Chorionic villus from the second month; the OCCUOV at least One-half of the OVary, 

syncytium provided with prickle processes: (J. Cap) foetal m rj . J * 

capillary. (.H.-Z) Hofbauer cell. X400. (Keibel and projecting - from the Surface as a 

Mall.) r J ° 

more or less permanent 
hillock. It does not differ histologically from the menstrual corpus luteum, 
and its increased size has been attributed to the marked congestion of the 
vessels incident to pregnancy. Some authors, however, notably Fraenkel, 
believe that the corpus luteum is the actual 
secreting structure of the ovary and is directly 
concerned with the formation of the decidua 
and placenta and the nourishment of the early 
ovum. Later in pregnancy, when these changes 
have occurred, the corpus luteum undergoes 
atrophy. Fraenkel, by careful experimental 
investigations, has done much to substantiate 
his theory, and his views are now generally 
accepted. The vascularity of the Fallopian tubes 
is increased, and they undergo some hypertrophy. 
The vagina is more vascular, and its mus- 
cular and connective-tissue fibers become hyper- 
trophied. The vaginal mucosa becomes thicker and softer. The distention of the 
abdominal wall by the pregnant uterus is marked in more than 90 per cent, of 
cases by the formation of the striae gravidarum. These striae are shimmering, 





Fig. 86. — Human ovum, showing cho- 
rionic villi. (Specimen of Dr. G. A. 
Piersol.) 



PHYSIOLOGY 



77 



Ch.-P. 







ife '.<W««! 



z.-/. 




R.F-. 



N.F.^r 



M- 



Dr, 



Fig. 87. — Anlage of the placenta from the second month. From a uterus obtained per opera- 
tionem. The embryo had a vertex-breech length of 28 mm. {Ch.-P) chorion plate; (Dr) glands; 
(b.E) basal ectoderm; (Hz) anchoring villi; (M) muscularis uteri; (m.A) maternal artery in a 
placental septum (decidual pillar); (N.F) Nitabuch's fibrin stria; (R.F) Rohr's fibrin stria; 
(Z.-J) cell island. X15. Keibel and Mall.) 

pinkish, bluish, or whitish depressed areas that appear at the sides of the 
lower abdomen and adjacent surface of the thighs. They are the result of 
overstretching, atrophy, or rupture of the deeper connective-tissue layers of 



78 



GYNECOLOGY 




Fig. 88. — The pregnant uterus at term, showing the 

fundus, the lower uterine segment and the cervix. 

Schematic. 



Fig. 89. — Pregnant uterus at end of first stage of 
labor; the upper uterine segment is the contracting 
part, the lower uterine segment and the cervix are 

the dilating parts. 




Fig. 90. — The height of the fundus of the pregnant uterus at different periods. 



PHYSIOLOGY 



79 



the skin. The pressure of the growing uterus frequently causes stretching 
of the linea alba and separation of the rectus muscles. Diastasis of the recti 
and thinning of the fascia are so marked at times that the anterior surface 
of the uterus is brought very close to the skin and is separated from it only 
by the attenuated fascia and peritoneum. During the latter months of preg- 
nancy the enlarged uterus acts as an obstruction to the venous circulation, 




FlG. oi, g and b. — Showing the softening of the lower uterine segment of early pregnancy (Hegar's 
sign) and the extent to which the tissue may be compressed between the examining fingers. 

so that enlargement and varicosity of the veins of the lower extremities are 
frequent and oedema is not unusual. As the uterus hypertrophies it presses 
more and more upon the bladder. Toward the end of pregnancy the bladder be- 
comes elevated, and finally a considerable portion of it lies above the pelvic brim. 

LABOR 

Dilatation of the cervix may occur gradually during the last weeks of 
pregnancy or not until labor begins (Fig. 92). The internal os is the first 
to undergo dilatation, followed by a gradual, cone-like distention of the 
tissue surrounding the cervical canal. Finally the canal of the cervix be- 
comes obliterated, and only the external os remains. The edges of the 






Fig. 92. — Showing the gradual obliteration of the internal cs and cervical 
canal at the end of pregnancy. 

external os gradually become thinner and retracted over the advancing fcetal 
parts. During this stage tears of the cervical tissue (Fig. 93), beginning 
at the thinned-out edges of the os, are not infrequent, and to a certain extent 
are almost physiologic (Fig. 94). As the head of the foetus is propelled through 
the pelvic canal by the force of the uterine contractions, assisted in the 
second stage by voluntary contraction of the abdominal muscles, it presses 
upon the structures that separate the uterovaginal canal from the pelvic 
bones. The lower uterine segment, cervix, vagina, bladder, rectum, and 



80 



GYNECOLOGY 




Fig. 93. — The vaginal wall being torn 
from its attachments and pushed for- 
ward by the advance of the foetal head 
during labor, a factor in the production 
of cystocele. 



muscles, fascia, nerves, and vessels of the pelvic wall are compressed to a 
degree corresponding to the relative disproportion in size between the bony 

pelvis and the child's head (Fig. 95). When the 
presenting part reaches the perineal floor the 
structures anterior to the vagina are forced for- 
ward against the posterior surface of the sym- 
physis, and those that lie behind are pushed 
downward and backward and greatly stretched, 
finally forming the posterior and lateral bound- 
aries of what is termed by Williams the " peri- 
neal gutter." As the head approaches the vaginal 
outlet the pressure on the lower part of the rec- 
tum causes the anus first to bulge and then to 
dilate and expose the mucosa of the anterior 
rectal wall. At the moment of birth the vaginal 
orifice is greatly overstretched and its borders 
are thin and tense (Fig. 96). Tears in the 
fourchette, in the mucosa, and in the edges of the 
triangular ligament surrounding the orifice 
are common. If the disproportion is too 
great or expulsion occurs before the parts 
are fully dilated, rupture of the perineal 
muscles and fascia may occur. 

The third stage of labor consists of sepa- 
ration and expulsion of the placenta. The 
placenta is detached from the uterine wall 
by the contractions of the uterus, which re- 
duce greatly the placental area of attach- 
ment. The attached placenta follows the 
uterine contraction to a certain extent, but 
after it has become diminished in size as far 
as is compatible with its area of attachment, 
it leaves the uterine wall. The placenta and 
membranes are expelled by uterine contrac- 
tions, such expulsion being aided in certain 
cases by bleeding and by the formation of a 
clot between the placenta and the uterine 
wall. 

Abortion or miscarriage is a diminutive 
form of labor, since the foetus is smaller and 
there is less disproportion in size between 
it and the birth-canal. Traumatism is, 
therefore, reduced to a minimum, and may 
be almost entirely absent. Usually, how- 
ever, there is some laceration of the cervix, 
but the perineum commonly escapes in- 
jury. The earlier the abortion, the more frequently is expulsion of the 
placenta attended by difficulty, artificial means being occasionally required. 







Fig. 94. — Bilateral laceration and elongation 

of the anterior lip of the cervix. Sketch 

made few hours after spontaneous delivery 

of primipara. (Philadelphia Hospital.) 



PHYSIOLOGY 



81 



Portions of the placenta or decidua are retained in utero much more fre- 
quently in abortion than in labor at term. 

THE PUERPERIUM 

For five or six weeks following labor the uterus and the other pelvic 
organs that hypertrophied during pregnancy become the seat of regressive 
changes that permit them to approximately return to their previous normal con- 
dition. This period is known as the puerperium, and the regressive process 
as involution. Involution is accomplished by atrophy of the muscle cells, 
obliteration of many of the vascular channels, and absorption of the tissue 




Fig. 95. — Distention of the perineal muscles by the birth of the head. 



juices. It affects the uterus, uterine ligaments, ovaries, tubes, abdominal 
walls, cervix, vagina, and perineum. These parts never return absolutely 
to their former state, but retain certain marks or indications of the preg- 
nancy. The completeness of involution is dependent upon the proper 
management of labor and the puerperium and upon the general health of 
the patient. Involution may be retarded by accidents during delivery, by 
infection, by retention of the membranes and placenta, by insufficient or 
improper care, e.g., too early resumption of activity, heavy lifting, and the like, 
and by general debility and lack of tone. 

During the first ten days or two weeks of the puerperium a bloody 
vaginal discharge, known as the lochia, is present. This at first consists of 



82 



GYNECOLOGY 



pure blood, but later becomes mixed with shreds of decidua, bits of mem- 
brane, leucocytes, and epithelium. The bloody constituent grows less and 
less until the tenth day, when, as a rule, the discharge is made up wholly of 
leucocytes and epithelial debris. The lochia diminishes progressively in 
quantity and finally ceases. Commonly, however, after a woman has borne 
a child, there is a slightly increased secretion from the vagina. This is due 
to the slight hypertrophy of the uterus and its glandular constituents which 
often persists. 

THE MENOPAUSE 

The menopause, climacteric, or change of life occurs at about the forty- 
fifth year. It corresponds to the end of ovulation and the exhaustion of the 








FlG. 96. — Showing the distention of the perineum just before the birth of the head and the episiotomy 

incision and scheme of closure. 



primordial follicles in the ovary. The internal secretion of the ovaries 
fails, the uterus and the other generative organs atrophy (Fig. 97), 
menstruation ceases, and conception is no longer possible. In other words, 
the reproductive period of the woman's life is at an end. The menstrual 
flow may cease abruptly or may gradually decrease in amount, or the inter- 
vals between the menstrual epochs may become longer. Normally, the 
amount lost at each period is diminished and the number of periods are 
lowered, not increased. Accompanying the abrupt or gradual cessation of 
menstruation certain nervous symptoms appear that are believed to result 



PHYSIOLOGY 



83 



from the cessation of the internal secretion of the ovary. These symptoms 
consist of periodic vasomotor relaxation affecting the entire body, particu- 
larly the upper extremities and face, and described by the patient as sensa- 
tions of heat or " flashes." General nervous symptoms and perversions of 
inclination and disposition are also observed. Ordinarily, the menopausal 
disturbances subside within one or two years. They vary considerably in 
degree, being exaggerated in some patients and scarcely noticeable in others. 
There is often a general increase in the development of adipose tissue. The 
vulvar and vaginal mucosa loses its flexibility and becomes attenuated, in- 
elastic, and tender. The vulva atrophies, and the vaginal orifice and vaginal 
canal contract. The slightest trauma, mechanical, chemical, or thermal, 
may give rise to a vulvovaginitis. The atrophy of the genitalia may be 
associated with exaggeration of a previously existing cystocele, rectocele, 
or malposition of the uterus. 




Fig. 97. — Atrophic changes in a senile uterus with shrunken appendages of the left side. From a woman 
aged sixty-eight years. The tube and utero-ovarian ligament appear abnormally elongated. (Gyneco- 
logical Laboratory, U. of P.) 

The menopause may occur prematurely from early exhaustion of the 
ovary, the result probably of deficient development. In these cases the 
menses disappear gradually or suddenly, and nervous symptoms are prone 
to be marked. A premature menopause is usually associated with obesity 
and with other evidences of hypoplasia of the genital organs, e.g., late 
puberty, scanty menses, and sterility. Deficiency or abnormality of the 
secretion of the other ductless glands appears at times to be associated with 
a premature menopause. 

The menopause may be brought on abruptly by operations that remove 
the ovaries and thus deprive the body of their internal secretion. In these 
cases the menses do not reappear, and the patient often suffers severely 
from " hot flashes," nervousness, headaches, and the like. In a neuropathic 
individual pronounced psychosis may take place. 

The Excretions of the Genitalia.— -The excretory products of the glands 
of the genital tract vary in their nature and purpose. Upon the external and 
hairy surfaces, as elsewhere in the body, there is an excretion of sebaceous 
matter and perspiration. The more delicate inner surfaces of the vulvar 



84 GYNECOLOGY 

mucosa are kept moist by the thin, mucous excretion of the vestibular and 
Bartholinian glands. The cervical glands excrete a thick mucus which 
plugs the cervical canal, and which, while serving to prevent the entrance 
of bacteria, attracts the spermatic particles. The so-called vaginal secre- 
tion consists of desquamated epithelium from the vagina mixed with mucus 
from the cervix. The secretion of the endometrial glands is greatest just 
before and at the time of the menses ; mixed with blood it forms the 
menstrual fluid. 

THE URINARY ORGANS. 

The Ureters. — The ureters are tubes that serve to convey urine from 
the pelvis of the kidney to the bladder. This function is partly due to 
gravity, but occurs mostly as the result of the peristaltic muscular contrac- 
tions of the ureteral wall. Inspection of the ureteral orifices during cysto- 
scopic examination shows that periodic spurts occur at more or less regular 
intervals. The discharge of urine is preceded by a relaxation of the ureteral 
opening and by a vermicular motion of the vesical part. 

Backflow of urine from the bladder to the ureter is prevented by com- 
pression of the vesical ureter incident to distention of the bladder, and a 
valve-like approximation of the margins of the ureteral openings. Backflow 
into the urinary tubules from distention of the kidney pelvis is prevented by 
compression of the renal pyramids and closure of the tubules. 

The Bladder. — The bladder is the reservoir in which the urine collects, 
and by which organ it is expelled. The base, including the trigone, is more 
or less fixed, being attached to the anterior vaginal wall and the cervix. 
The apex, on the contrary, is free, and as the bladder fills it rises into the 
pelvic cavity, pushing the body of the uterus, which lies in contact with it, 
upward and backward. After evacuation is completed the summit sinks again into 
the lower and more fixed vesical areas. The urine is retained in the bladder up 
to a certain degree of distention by the elasticity of the fibers surrounding 
the urethra and by the sphincter muscle. Beyond that point the vesico- 
spinal center is excited, and a contraction of the unstriated vesical muscle 
is produced through the motor nerves, After the age of infancy this process 
is influenced by a voluntary inhibition of the vesical center and contraction 
of the urethral sphincter. The sensory excitor-reflex nerves of the bladder 
may, also, be stimulated, even though there is but moderate distention of the 
viscus by voluntary contractions of the striated muscles of the urethra, the 
floor of the pelvis, or the abdominal wall, or by the irritation of sensory 
nerves, as by tickling or by the sound of running water or whistling. The 
vesical center may also be stimulated by tumors and by malpositions and 
adhesions of the pelvic organs that produce traction or pressure upon the 
bladder. Frequency of urination is a common symptom of gross pelvic dis- 
ease, even where the urine is normal and no cystitis is present. 

The Rectum. — The rectum is the lower part of the large intestine which 
serves as a receptacle for the faeces, from which they are expelled by muscular 
action. The intestinal contents are inspissated higher up the intestinal canal, 
and formed into a fecal mass. Above the rectum the faeces give no sign of 
their presence, but as soon as they enter the rectum the anospinal center in 



PHYSIOLOGY 85 

the lumbar cord is excited and energetic peristalsis is induced. As the fecal 
mass enters the anal canal a voluntary inhibition of the sphincter ani muscles 
permits these structures to relax and a portion of the fecal mass to pass 
through the canal. Immediately thereafter contraction of both the levator 
ani and the sphincter ani muscle occurs. The direction taken by the fibers 
of the levator ani muscles makes it possible for them to aid the sphincter 
in closing the anus immediately after a portion of the fecal contents has 
been expelled. The external sphincter is prevented from being pulled for- 
ward by its attachment to the coccyx, so that its contraction, plus the 
elevating action of the levators, results in a sort of cut-off action at the 
rectal outlet. Defecation may be controlled for a time by voluntary con- 
traction of the external sphincter, but peristalsis may be so energetic as to 
offset the strongest voluntary contraction. Expulsion of the faeces is usually 
assisted by voluntary contractions of the muscles of the abdominal wall, 
together with inspiratory depression of the diaphragm. 

Constipation and difficult and painful defecation are not uncommon 
consequences of pelvic disease. Rectal irritability and a frequent desire to 
empty the bowel are notably observed in cases of extrauterine pregnancy 
with pelvic hematocele. 

BIBLIOGRAPHY 

American Gynecological Society, 1917. Symposium on " The Relation of the Glands of 
Internal Secretion to Gynecology and Obstetrics." Frank, Gcetsch, McCord, 
Vcegtlin, Pool, Marine, Pappenheimer, Graves, Morley. 

Arnold : " Ueber das zeitlichen Verhaltniss der Ovulation zur menstruelle Blutung." 
Inaug. Dissert., Wurzburg, 1897. 

Bell, W. B. : " Causes of Noncoagulability of Normal Menstrual Blood and of Patho- 
logic Clotting." J. Path, and Bact.. 1914, xcii, p. 462. 

Clark, J. G. : " The Origin, Development and Degeneration of the Blood-Vessels of 
the Human Ovary." Bull. Johns Hopkins Hospital, 1899. x, p. 40. Ibid. : " The 
Origin, Growth and Fate of the Corpus Luteum," loc. cit., 1898, vii, 181. Ibid.: "The 
Anatomical Basis of Ovulation and Menstruation." Trans. Amer. Gyn. Soc, 191 1, 
vol. xxxvi, p. 265. 

Das, Kedarnath : Handbook of Obstetrics. Butterworth & Co., Calcutta, 1914. 

Dienst, A. : " Die Ursache fur die Gerinnungsunfahigeit des Blutes bei der Menstrua- 
tion." Mimchen. med. Wchnschr., 1912, fix, 2799. 

Edgar, J. C. : Practice of Obstetrics. Blakiston, Phila., 1913. 

Ehrenfest, Hugo : " The Influence of the Central Nervous System in the Causation of 
Uterine Hemorrhage." Am. Jour. Obst., 1908, lvii, p. 161. 

Engelmann, G. J.: "Das Alter bei der ersten Menstruation, Am Pol und Am Aquator." 
Centralbl. f. Gynak., 1902, No. 46, 1125. 

Findley, P. : " Menstruation) Without Ovaries." Trans. Amer. Gyn. Soc, 1912, vol. 
xxxvii, p. 82. 

Frank, R. T. : " The Clinical Manifestations of Diseases of the Glands of Internal 
Secretion in Gynecological and Obstetrical Patients." Surg., Gynec, and Obst., 
1914, xix, p. 618. Ibid. : " The Function of the Ovary." Trans. Amer. Gyn. Soc, 1911, 
vol. 36, p. 269. Ibid. : " The Placenta Regarded as a Gland of Internal Secretion." 
Loc. cit., 1917, vol. 42, p. 240. 

Fraenkel, L. : " Die Funktion des Corpus Luteum." Arch, f . Gynak., vol. lxviii, p. 438. 
Ibid. : " Neue Experiments zur Funktion des Corpus Luteum." Arch, f . Gynak., 1910, 
vol. xci, p. 705. Ibid. : " Ovulation, Konzeption und Schwangerschaftsdauer." Ztschr. 
f. Geburtsh. u. Gynak., 1913, vol. lxxiv, p. 107. 

Gebhard, C. : "Ueber das Verhalten der Uterusschleimhaut bei der Menstruation." 
Ztschr. f . Geburtsh. u. Gynak., 1895, vol. xxxii, p. 296. Ibid. : " Die Menstruation." 
Handbuch d. Gynakologie, J. Veit, Wiesbaden, 1897, vol. iii, part 1, p. 18. 

Gelhorn : Discussion. Trans. Amer. Gyn. Soc, 1917, vol. xlii, p. 317. 

His: " Anatomie menschlichen Embryonen." Abtb. 1, v, ii, Leipzig, 1882. 



86 GYNECOLOGY 

Hitschmann and Adler : " Der Bau des Uterusschleimhaut." Monatschr. f. Geburtsh. 

u. Gynak., 1908, vol. xxvii, No. 1. 
Keibel, Franz, and Mall, Franklin P. : Manual of Human Embryology. Lippincott, 

Phila., 1910. 
Kisch, E. Heinrich : Das Geschlechtsleben des Weibes. Urban, Berlin, 1907. 
Kollmann, J. : Handatlas der Entwicklungsgeschichte des Menschen. Fischer, Jena, 1907. 
Landois, L. : Text-Book of Human Physiology. Blakiston, Phila., 1904. 
Leopold and Miranoff, M. : " Beitrage zur Lehre von der Menstruation und Ovulation." 

Arch. f. Gynak., 1893-94, xiv, 506. 
Meyer, R., and Ruge, C. : " Ueber Corpus Luteum Bildung und Menstruation in ihrer 

zeitlichen Zusammengehorigkeit." Centralbl. f. Gynak., 1913, xxxvii, 1st half, 50. 
Novak, Emil: "The Corpus Luteum." J. A. M. A., 1916, vol. lxvii, p. 1285. Ibid. : 

" The Superstition and Folklore of Menstruation," loc. cit., vol. xxvii, No. 307, 

September, 1916. 
Ott, D. v. : " Gesetz der Periodicitat der physiologischer Funktion in weiblicher Organ- 

ismus." Bericht. iiber die Verhand. d. X. Int. Med. Cong., Berlin, 1890, Centralbl. 

f. Gynak., 1890, Beilage, 31. 
Peters : " Schwangerschaftsdauer." Centralbl. f . Gyniik., 1915, vol. xxix, 1st half, 261 

and 276 ; Ibid. : " Ueber die menschlichen Eies." Deuticke, Leipzig und Wien, 1899. 
Schroeder, R. : " Ueber der zeitlichen Beziehungen der Ovulation und Menstruation." 

Arch. f. Gynak., 1914, vol. ci, p. 1. 
Stengel, A. : " Ovulation and Menstruation." Univ. Med. Mag., 1891, Hi, 233. 
Williams, J. Whitridge: Obstetrics. Appleton, New York, 1912. 



CHAPTER V 
THE CAUSES OF PELVIC DISORDERS 

Diseases of the female genital tract may be either inherited or acquired. 
Congenital disorders may be evident at birth or may appear later — at 
puberty, during the reproductive period, at the menopause, or even later. 
Among the congenital disorders that are evident at birth are gross malforma- 
tions or tumors ; those that manifest themselves at puberty are such condi- 
tions as prevent the normal establishment of menstruation ; those that appear 
first during the reproductive period are such as obstruct or compli- 
cate reproductions, or tumors, as, for example, fibroids and sarcoma. Con- 
genital diseases developing later include true ovarian cysts or solid tumors 
or possibly carcinomata (if these can be considered as congenital). 

In addition to these congenital or inherited disorders pelvic diseases may 
have their origin in general or constitutional lesions that affect the pelvic 
structures indirectly — as, for example, ancvmia or heart disease, which influ- 
ence the pelvic circulation and the menstrual flow, or directly, as in certain 
metastatic infections, such as oophoritis following mumps, or a tuberculosis 
of the tubes secondary to a tuberculous focus elsewhere in the body. Atresia 
of the vagina the result of the exanthemata of childhood may, upon discovery 
in later life, appear to be congenital, but in reality is an acquired lesion. 

Functional disorders, such as severe dysmenorrhcea associated with 
irregular and scanty periods, may also be congenital. They are the evi- 
dences of an underdevelopment of the genitalia, a condition frequently asso- 
ciated with chlorosis and an arrested development of the entire cardiovascu- 
lar system. These painful and distressing functional disorders may also be 
acquired as the result of ill-health and of arrested growth and development 
after the individual has attained the age of puberty. Even after adult life 
has been reached, depressing conditions of body and mind, such as tedious 
sedentary occupations, insufficient exercise, faulty hygienic conditions, pro- 
longed worry, improper food, may give rise to the symptoms of 
functional disorders. 

An unnatural sexual state may also play a part in these conditions. 
Celibacy and ungratified sexual impulses, even though subconscious, may 
influence the menstrual function and upset the nervous balance of 
the individual. 

Pain at the menstrual periods (dysmenorrhcea), if chronic, may induce 
permanent manifestations of nervous irritability, exhaustion, and depression, 
even in persons not predisposed to nervous disease. 

In many individuals an unstable nervous organization is associated with 
dysmenorrhcea of the so-called essential or neurotic type, that is, dysmenor- 
rhcea having no anatomic basis other than a hypoplasia. In these cases the 
dysmenorrhcea aggravates the neurotic condition and leads to nervous irri- 
tability, exhaustion, and depression. 

Amenorrhcea and menorrhagia may in turn produce or be produced by 

87 



88 GYNECOLOGY 

nervous disorders. Amenorrhoea and the fear of tuberculosis, menorrhagia 
and the dread of cancer, may tend to produce psychoneurotic conditions. 
So, too, the fear of impregnation or the desire for conception may cause 
amenorrhoea, whereas sudden mental shocks and other nervous disturbance 
may be the underlying cause of menorrhagia (Ehrenfest). 

. Possibly the largest group of pelvic diseases are those due to pregnancy 
and labor or to their complications. In this class belong ectopic develop- 
ment of the ovum, the traumatism incident to labor and the results of such 
injury, and the infections that follow labor or miscarriage. 

Certain tumors of the genital tract have their origin in the rests of 
embryonic organs or structures that ordinarily remain inactive. In this 
class may be included the true glandular cysts of the ovary, parovarian 
cysts, and adenomyomata outside the uterus. 

Carcinoma may affect any portion of the genital tract. When it attacks 
the vulva, it usually occurs late in life, and is often a sequel to leucoplakia 
vulvae. Carcinoma of the vagina is generally secondary to carcinoma of the 
cervix or of the body of the uterus. Carcinoma of the cervix is most com- 
mon in women who have borne children, giving rise to the belief that trauma 
of the cervix plays an important role in its production. Carcinoma of the 
body of the uterus often follows in the wake of myoma of the uterine wall. 
Carcinoma of the ovary frequently results from degeneration of a glandular 
cyst. The etiology of malignant growths of the genital tract, as elsewhere 
in the body, is obscure. Some investigators regard them as the end-results 
of infection by a microorganism or a parasite, a theory that has not been 
borne out by facts. 

Fibroid tumor is possibly always congenital in origin, the original nidus 
from which the tumor grew having been present in the genital tract at the 
time of birth. It is an assured fact that some of these tumors never increase in 
size or produce symptoms. Why this is so has never been discovered. 

Dermoid tumors of the ovary are teratomatous inclusions that have 
existed since foetal life. 

Chorioepithelioma is a term applied to a malignant degeneration of the 
chorionic villi of an antecedent pregnancy. 

Infections incident to sexual life, such as gonorrhoea, syphilis, and chan- 
croid, especially the first, are responsible for many forms of pelvic disease. 
Syphilis is much more frequent in the female than has generally been sup- 
posed. It gives rise to definite lesions of the external genitalia and the 
cervix, and affects the functions of the genitalia in many ways. 

The bacteriology of the generative tract is of considerable importance in 
this connection, for inflammatory diseases occupy a prominent place among 
the pathologic conditions to which the generative tract is subject. Some 
of the bacteria that produce pathologic lesions in the genitalia are those 
which are found normally in the alimentary tract and upon the skin surface 
of the vulva and perineum. Any of the usual inhabitants of the mouth and 
nasopharynx may find their way into the stomach, but many of them never 
survive the action of the gastric juice. The duodenum and small intestine 
contain fewer organisms than the large intestine, where they are very numerous. 

The most common intestinal form of bacteria is the bacillus coli com- 



THE CAUSES OF PELVIC DISORDERS 89 

munis. Other less well-known varieties are the bacillus lactis aerogenes 
and bacillus fecalis alcaligenes. The streptococcus pyogenes, staphylo- 
coccus aureus and albus, and bacillus pyocyaneus are often present in the intes- 
tinal tract, the surface of the perineum, and the external genitalia. All the 
intestinal bacteria may be found in greater or lesser numbers on the skin in 
the region of the anus, perineum, external genitalia, and groin. 

The vagina is the habitat of a rod-shaped bacillus described by Doder- 
lein, and known as the bacillus doderleini. This bacillus is anaerobic and 
has an acid secretion. By reason of their secretion the vaginal organisms 
exert a bactericidal action upon the pathogenic bacteria that are deposited 
there, unless, by reason of the excessive numbers or virulence of the latter 
the bactericidal properties of the Doderlein bacilli are overcome. 

The normal endometrium and tubes are sterile. The organisms most 
frequently responsible for the occurrence of pathogenic changes in the 
genitalia are the gonococcus, streptococcus pyogenes, staphylococcus albus 
and aureus, colon bacillus, and tubercle bacillus. The gonococcus is trans- 
mitted by sexual contact ; the streptococcus and staphylococcus are intro- 
duced into the genital tract as the result of examination or instrumentation ; 
the colon bacillus is either introduced by manual or instrumental examina- 
tion, or reaches the tubes by way of the adjacent intestinal walls. 

A tuberculous infection of the genitalia is usually secondary. It is gen- 
erally a hematogenous infection, and reaches the tubes by way of the blood- 
stream. Other more or less accidental infections with almost any patho- 
genic organism may occur. Thus the diphtheria bacillus, pneumococcus, 
bacillus pyocyaneus, bacillus aerogenes capsulatus, typhoid bacillus, and 
streptothrix actinomyces may all occasionally find lodgment in the genital 
tract and set up an active inflammation. 

Aside from the tuberculous infections, however, we are most concerned 
with gonococcus infections, on the one hand, and with streptococcus and 
staphylococcus infections on the other. This is due to the difference in the 
behavior of the two types of organisms when deposited in the genital tract, 
and to the difference in the clinical history, symptoms, and course of the 
two forms of infection they produce. 

Although the gonococcus lodges only in delicate epithelium, any break 
or abrasion of the mucous membrane, no matter how trifling, may form a 
nidus for the invasion of the streptococcus and the staphylococcus. The 
gonococcus reaches the pelvic structures by extension along a mucous sur- 
face ; the other organisms, on the contrary, are prone to extend directly 
through the lymph-channels leading from the area in which they were origi- 
nally deposited. For example, both the gonococcus and the streptococcus 
may be deposited directly within the uterus, and thus infect the endometrium, 
but the gonococcus infection will reach the tubes by extension along the 
mucosa, whereas the streptococcus will penetrate the uterine wall, pass into 
the broad ligament, and reach the tube from the outside, involving the 
peritoneal surfaces exclusively before invading the mucous membranes. The 
gonococcus usually leaves the ovary uninjured, except for the local irrita- 
tion it produces in the adjacent tissues and the gross deposits of a surround- 
ing peritonitis. A streptococcus or a staphylococcus infection, on the other 



90 GYNECOLOGY 

hand, very often attacks the ovary directly, penetrates the ovarian stroma, 
and produces an abscess. It may also be the cause of abscess formation of 
the broad ligament or of the uterine wall. 

BIBLIOGRAPHY 

Bumm : Der Mikroorganismus d. gonorrh. Schleimhauterkrankungen. Wiesbaden, 1885. 
Curtis, A. H. : " The Etiology and Bacteriology of Leukorrhea." Surg., Gyn., and Obst., 

1914, xviii, p. 299. 
Doderlein : Das Scheidensekret und seine Bedeutung f iir das Puerperalfieber. Leipzig, 

1892. 
Ducrey : " Experimented Untersuchungen iiber das Kontagium des weichen Schankers." 

Monats. f, prakt. Dermat, 1889, Bd. 9, S. 221. 
Escherich, Th. : Darmbacterien des Saiiglings und ihre Beziehung zur Physiologie der 

Verdauung. Stuttgart, 1885. 
Harada, Takashi : " On the Nature of the Bactericidal Property of Vaginal Secretion." 

Amer. Jour. Med. Sci., 1916, vol. clii. p. 243. 
Hunner: "The Streptococcus in Gynecology." Amer. Gyn. and Obst. Jour., May, 1901, 

vol. xviii, p. 404. 
Koch : " Die Aetiologie der Tuberculose." Berlin, klin. Wochenschr., 1882, Bd. xix. 
Little, H. M. : " The Bacteriology of the Puerperal Uterus." Amer. Jour. Obst., 1905, 

vol. Hi, p. 815. 
Menge und Kronig : Bakteriologie des weiblichen Genitalkanales. Leipzig, 1897. 
Neisser : " Die Mikrokokken der Gonorrhea." Deutsche med. Wochensch., 1882, Bd. 

viii, S. 279. Ibid.: " Ueber eine der Gonorrhea eigenthumliche Micrococcusform." 

Centralbl. f. d. med. Wissensch., 1879, Bd. xvii, S. 497. 
Opitz : " Bakteriologische Uterus-Untersuchungen." Cent. f. Gynak., 1897, No. 52, 

5, 1505. 

Penrose, C. B. : A Text-Book of Diseases of Women. Saunders, Phila., 1900. 

Ploss, H. : Das Weib in der Natur und Volkerkunde. Grieben. Th. Leipzig, 1905. 

Schaudinn, F. : " Zur Kentniss der Spirochcete Pallida." Deutsch. med. Wochenschr., 1905, 
No. 42, p. 1665. 

Walthard : Handbuch d. Geburtsh., v. Winkel. vol. iii, 2. 

Williams. J. W. : "The Bacteria of the Vagina and Their Practical Significance." Amer. 
Jour. Obst., 1898, vol. xxxviii, p. 449. Ibid.: "Tuberculosis of the Female Genera- 
tive Organs." J. H. H. Reports, 1893, vol. iii, p. 85. 



CHAPTER VI 
HISTORY-TAKING AND SYMPTOMATOLOGY 

Taking the history of the case forms an important preliminary to the physi- 
cal examination. In order to direct his inquiries intelligently and to sepa- 
rate the important from the unimportant, the interrogator must be thor- 
oughly familiar with the normal anatomy and physiology of the generative 
organs., as well as with the nature and course of the pathologic conditions 
that are common to them (Fig. 98). 

The patient is often timid and apprehensive, and the physician's manner 
should be such and the questions be so put as not to offend, alarm, or 
excite her. A badly-chosen question may be misconstrued by a nervous 
woman and throw her into a state of the greatest agitation. It is a good 
plan, therefore, to let the patient tell her story in her own way, This in- 
variably gives her the assurance that an interest is being taken in her case, 
and paves the way for most searching questions later on. While she is 
giving an account of her sufferings, the physician has an opportunity to 
learn the patient's temperament — whether she exaggerates or minimizes 
her symptoms, whether she is depressed or buoyant in nature, and be en- 
abled to determine the course to be pursued in order to obtain her 
fullest confidence. 

A printed form may be utilized in recording the facts elicited, although 
a blank with suitable spacing for each subject in every case is often im- 
practicable, for what is irrelevant to one case may be most pertinent to 
another. In order, however, to preserve system and to secure uniformity it 
is necessary that the data be recorded under separate headings. 

Chief Complaint. — The examiner should bear constantly in mind the 
particular symptom or group of symptoms that have led the patient to 
consult a physician and from which she desires to secure relief. Thus an 
excellent anatomic result may be secured as the result of an operation to 
correct the position of the uterus, and yet, if the patient's chief complaint 
was of vesical irritability due to a urethral caruncle, or of backache the result 
of a sacroiliac sprain, she may consider her condition as unimproved. In 
making the diagnosis and prescribing the treatment attention should, there- 
fore, be focussed on the most troublesome symptom. To this should be 
added the minor complaints, the number of which may give some indication 
of the patient's general condition and of her tendency to exaggerate or 
minimize her symptoms. 

Age and Social State. — The age of the patient, whether she appears to 
be older or younger than the given age, whether she is single, married, or 
widowed, are points to be elicited at the beginning of the examination or 
later. It is often wise to postpone these inquiries for a time. If the patient 
is single, some idea as to whether or not she is virginal may be gained 
from her personality and occupation. These data are all of considerable 
importance, since there are certain diseases that are more common at cer- 

91 



92 



GYNECOLOGY 



Name Age , S. M. W. Color Born Consulted at 

Address Referred by Date 

Chief Complaint 

Menses began at ; type established by ; menstrual type: recurrence every ; duration ; quantity ; pain 

; possibly the result of 

; duration ; quantity ; pain ; Last period 



Variation in menses at 
Menses at present: recurs every 

Leucorrhea since ; occurs ; amount ; color 

Married at age of ; pregnancies 

Labors ; date of each ; character of labor 

Complications of puerperium 

Miscarriages , duration of pregnancy and date of each 

Probable cause complications during or after miscarriage 

Previous Diseases Treatment or Operations 
Parental or Family Disorders 
Present Symptoms developed 

Were attributed by patient to are possibly attributable to 

Symptoms referable to pelvis, including generative organs, bladder and rectum 



consistencv 



complications of labor 



Symptoms referable to stomach, gall bladder, appendix, intestines and kidneys 



Symptoms ( Heart 
referable -l Lungs 

to I Nervous system 

General Examination Weight 

Blood Examination 

Heart 

Pelvic Examination Vulva 

Ant. vaginal wall 

Uterus 

Right adnexa 

Left adnexa 

Abdominal Examination 

Diagnosis 



; temp. ; pulse 

urinalysis 
lungs 
; vaginal outlet ; urethra 



post, vaginal wall 



; perineum 



; respirations 



; vulvo vaginal glands 

; anus 



Treatment 



Fig. 



-Form of History. 



HISTORY-TAKING AND SYMPTOMATOLOGY 93 

tain ages and in certain social states. Before the age of puberty, but few- 
gynecologic conditions occur, since the genital organs are still undeveloped, 
and the usual causes of pelvic disorders are absent. Among the diseases 
encountered in infants are gonorrhceal vulvovaginitis, the result of accidental 
infection, and a grape-like sarcoma of the cervix; in older children malig- 
nant tumor of the ovary may develop, and tuberculous salpingitis and peri- 
tonitis secondary to tuberculous foci elsewhere may arise. Inflammation of 
the endometrium is occasionally a complication of the acute infectious dis- 
eases, such as pneumonia, typhoid fever, and dysentery ; ovaritis may com- 
plicate mumps, scarlet fever, or small-pox, and gynatresia, first discovered 
after puberty, has been definitely traced to inflammatory lesions of the 
genital tract complicating typhoid fever, small-pox, dysentery, typhus, 
pneumonia, erysipelas, scarlatina, diphtheria, and measles. 

After puberty and during adolescence, various disorders incident to the 
establishment of the menstrual function may arise. These may be due to 
actual anatomic lesions in the pelvis, such as hypoplasia of the ovaries and 
uterus, stenosis and pathologic anteflexion of the cervix; dysmenorrhcea or 
general diseases that affect the menstrual flow, e.g., chlorosis and cardiac in- 
sufficiency ; amenorrhcea, scanty menstruation, menorrhagia, and metorrhagia. 

In the case of virgins between the ages of twenty-one and forty the 
lesions due to gonorrhoea — except accidental infection (extremely rare) — 
pregnancy, and childbirth may be excluded. Hyperplasia of the endo- 
metrium, cervical polyp, and congenital erosion or lacerations of the cervix 
may give rise to leucorrhcea. General ill health, asthenia, and nervous exhaus- 
tion may manifest themselves in painful menstruation and scanty flow. 
Cardiac insufficiency, fibroid tumor, or endometrial polyp may give rise 
to menorrhagia. 

Between the ages of twenty-one and forty, in the married or in the non- 
virginal female, any of the lesions that result from a gonococcus infection 
or from pregnancy, with its sequelae, may occur. Among these are pelvic 
inflammatory diseases, uterine displacements, cervical lacerations, and re- 
laxation of the pelvic floor. Fibroid tumors affect frequently those who 
have not been pregnant. 

Between the ages of forty and sixty the most common lesions encoun- 
tered are ovarian cyst, carcinoma of the cervix or of the fundus, descensus 
or prolapsus uteri, hypertrophy of the cervix, and the late stages of cystocele 
and rectocele. Cervical carcinoma rarely occurs in those who have not 
borne children, whereas cancer of the body of the uterus, either alone or 
combined with fibroid tumor, may occur in sterile women. 

Occupation and Habits of Life. — These should be carefully investigated. 
Improper food, faulty personal hygiene, a lack of fresh air and sunlight, and 
the depressing grind of uncongenial or exacting work will affect the general 
health and may give rise to painful and scanty menstruation. The woman 
who has insufficient help, who lifts heavy burdens, and who continually 
sacrifices herseli for the good of her household is predisposed to subinvolu- 
tion, displacement of the uterus, diastasis of the rectus muscles, cystocele, 
and rectocele. A woman's struggle to gain a livelihood or the worry incident 
to marital infelicity may result in nervous exhaustion or lead to the false 



94 GYNECOLOGY 

belief that a pathologic condition of the sexual or reproductive organs is 
present. Idleness, luxurious living, and indulgent habits lead to obesity, 
muscular weakness, digestive disturbances, and pelvic congestion, with its 
sequelae. Such patients often exaggerate their symptoms and complain exces- 
sively, but make no effort at the self-denial which may be required in 
the treatment. 

Menstrual History. — In this country puberty occurs on the average be- 
tween the ages of twelve and fourteen. Early puberty is believed to be 
favored by hot climates, luxurious living, and sensual pursuits. Late 
puberty is said to be favored by cold climates, hard work, mental worry, and 
distress. From the investigations made by Englemann it would appear that 
the influence of climate is somewhat exaggerated. However that may be, 
in the United States puberty delayed beyond the age of fifteen is often 
indicative of a lowering of the general health. When the general signs of 
puberty appear and periodic attacks of pelvic pain without menstrual flow 
occur, some form of gynatresia may be suspected. 

When taking the history of menstruation, the characteristics of the men- 
strual flow at the beginning and after it had become well established 
should be ascertained. Such data are quite important in order to determine 
the so-called " menstrual habit ;" i.e., the periodicity, duration, amount, and 
subjective sensations of menstruation which are the rule in the individual 
case. Later in life variations from this menstrual habit are often significant 
in the history, and may be indicative of acquired diseases. In the average 
menstruation occurs at intervals of from twenty-eight to thirty-one days, 
but certain women in perfect health menstruate every twenty-five days or 
even twenty-one days. The duration of the flow varies from two to nine 
days, the average being from five to six days. The amount of menstrual 
fluid lost varies between three and nine ounces, although for obvious reasons 
it is difficult to estimate the amount correctly. 

Backache and discomfort in the lower abdomen are quite common dur- 
ing menstruation, although certain individuals may experience no disagree- 
able sensations whatever. When the suffering is severe or becomes so 
marked that the woman is incapacitated, dysmenorrhea is said to be present. 

In dysmenorrhea the pain is usually in the lower abdomen or in the back, 
but severe headache or neuralgia occurring only at the menstrual epochs 
may constitute a form of dysmenorrhea. One should determine whether 
there has been any variation from the menstrual habit, and if so, the time 
at which it occurred and whether it followed a change of climate, general 
illness, exhausting work, prolonged worry, a change in occupation, labor or 
miscarriage, etc. The date of the last menstruation -should always be 
ascertained lest pregnancy be overlooked. 

The menopause occurs on the average about the age of forty-five, but 
it may take place as early as thirty, or as late as fifty years. 

Pregnancies. — The duration of married life and the period of time that 
elapsed after marriage when conception first occurred may serve to indicate 
the presence of healthy or imperfectly developed or diseased pelvic organs. 
The date of the last pregnancy and the length of time that has elapsed since 
should be ascertained and compared with the interval that occurred between 



HISTORY-TAKING AND SYMPTOMATOLOGY 95 

marriage and the first conception. If conception occurred soon after mar- 
riage and was followed by a prolonged period of sterility, a lesion acquired 
during or as the result of the initial pregnancy may be preventing concep- 
tion. All these facts may be distinctly modified by the condition of the 
husband and by any measures that have been adopted for the prevention of 
conception. The examiner should ask whether previous pregnancies have 
been abnormal in any particular, and whether there were any complica- 
tions, such as eclampsia or nephritic or hepatic toxaemia. 

Labor. — The course and effects of labor have a very important bearing 
upon the possibility or probability of the existence of various lesions result- 
ing from injury during childbirth. Thus it should be ascertained whether 
the labor was long or short, whether anaesthesia was employed, whether 
forceps or any surgical measure was necessary, whether postpartum hemor- 
rhage occurred or any difficulty attended expulsion of the placenta, whether 
lacerations resulted, and whether sutures were introduced. Inquiries should 
also be made as to the probability of infection having taken place during 
labor or subinvolution and displacement having occurred afterward. For 
example, the patient should be asked if she had peritonitis, fever, milk-leg, 
or " blood poisoning " during the puerperium ; on what day she left her bed, 
and the care she exercised as regards lifting or doing heavy work. The 
duration of lactation may have had some bearing on the subsequent men- 
strual history and on the general health. Protracted lactation may result 
in hyperinvolution of the uterus and anaemia. 

Abortion. — The occurrence of a single abortion may have no particular 
significance, but repeated miscarriages are usually attributable to intent 
on the part of the patient or to the presence of a pelvic or gen- 
eral lesion that may be corrected. Every patient who has had an abor- 
tion has been subjected to the same possibility of infection, subinvolution, 
etc., that obtains in labor at term. If an abortion has occurred, inquiry 
should be made as to the month of pregnancy at which it took place, the 
probable cause thereof, what the symptoms were, how long they lasted, 
whether the patient secured the services of a physician, and whether instru- 
mental evacuation of the uterus was necessary. 

The history of a foreign body having been introduced into the uterus 
for the purpose of inducing abortion and the occurrence of fever, peritonitis, 
or of any symptom that might indicate subsequent infection point to the 
possibility of an existing inflammatory disease. Repeated abortions are 
usually indicative of syphilis, displacement of the uterus, or of wilful 
attempts to terminate gestation. 

Family History. — The family history may have no bearing whatever 
upon the condition of the patient. Although few pelvic disorders are in- 
herited, nevertheless some are secondary to extrapelvic lesions, as, for ex- 
ample, tuberculous salpingitis, the tendency to which, at least, may -descend 
from parent to offspring. Although the disease usually appears only in 
males and is transmitted only by females, hemophilia in the uncle is said at 
times to explain persistent menorrhagia in the niece. Syphilitic parents 
may transmit the luetic taint to their offspring. A predisposition to dia- 
betes, gout, rheumatism, neuralgia, migraine, mental or nervous disorders, 



96 GYNECOLOGY 

such as neurasthenia, hysteria, epilepsy, chorea, angioneurotic oedema, is 
often encountered in the children of parents so afflicted. While there is no 
proof here of the relation of cause and effect, it is interesting, at least, to 
note the occurrence of carcinoma or fibroid tumor in the female descend- 
ants of a victim of these disorders. The menstrual and reproductive history 
of the mother and sister may often be repeated in another member of the 
family who comes under observation. 

General Previous History. — Previously occurring diseases may have 
some bearing on the present illness. One need but mention pulmonary 
tuberculosis as an antecedent to tuberculous salpingitis, syphilis as a factor 
in uterine hemorrhage, myalgia as a possible explanation of backache, 
chlorosis as a manifestation of hypodevelopment of the generative organs 
and the circulatory system, neurasthenia, psychasthenia, epilepsy, or chorea 
as indications of an unstable nervous system. Certain disorders of infancy 
and childhood may have affected the pelvic organs without producing symp- 
toms at the time directing attention to them. The influence of early vulvo- 
vaginitis in the production of vaginal atresia, discovered later in life, should 
be kept in mind. That vulvovaginitis is commonly the result of gonorrhceal 
infection is well known, but it may be produced, secondarily, as the result 
of pneumonia, scarlatina, diphtheria, measles, dysentery, and typhus fever. 
Infectious diseases occurring in infancy and childhood may affect second- 
arily the uterus, tubes, and ovaries. Gonorrhceal vulvovaginitis of infants 
rarely reaches the endometrium. 1 The endometrium has been found af- 
fected in patients dying of pneumonia, typhoid fever, and dysentery, and 
Penrose has made the statement that " acute inflammation of the endo- 
metrium sometimes occurs during the exanthemata." It appears that any 
of the infectious fevers occurring during early life may affect the ovaries. 
Small-pox, scarlet fever, and parotitis are said to be especially prone to be 
complicated by parenchymatous changes in the ovaries, as, e.g., cloudy 
swelling or degeneration of the follicular epithelium. Noble observed a 
case of parotitis followed by evidences of ovaritis and subsequent amenor- 
rhcea for six or eight months. Involvement of the generative organs during 
the infectious fevers of early life is but rarely referred to in works on 
pediatrics. Nevertheless, the weight of evidence of careful observers is 
that these organs are often affected, but that the disturbance is of mild grade 
and soon disappears. Exceptionally the involvement is marked and the 
impairment may become permanent. 

Beginning of the Present Disorder. — It is well to ascertain whether the 
symptoms of which the patient complains date from the time of puberty, 
marriage, labor, abortion, traumatism, or the menopause, or whether they 
can be referred to no especial cause or occasion. 

Developmental anomalies first become manifest at the time of puberty 
or marriage ; gonococcus infection dates from marriage or from a suspicious 
intercourse ; gonorrhceal endometritis or peritonitis in a patient already in- 

1 Suppurative appendicitis in childhood has been said to interfere with the develop- 
ment of the genitalia and lead to infantilism, amenorrhcea, dysmenorrhoea, etc. It may un- 
doubtedly be associated with pelvic inflammation and be followed with adhesions which 
close the tubes and lead to sterility in later life. Many cases of otherwise unexplained 
pelvic adhesions may be due to this cause. 



HISTORY-TAKING AND SYMPTOMATOLOGY 97 

fected frequently sets in about the time of a menstrual period; symptoms 
of uterine displacement, cervical laceration, and relaxation of the pelvic 
floor are referred usually to parturition. 

Present Symptoms — Pain. — Pain in the external genitalia accompanies 
inflammatory and other diseases of the vulva. It may be referred to the 
vulva from the ureter and kidney. Pain in the bladder and urethra is a 
symptom of urinary lesions, as, for example, inflammatory condi- 
tions, such as cystitis, urethritis, calculus, new growths (papilloma, ure- 
thral caruncle), and vesicourethral fissure. Frequent and painful urination 
may be a symptom of any pelvic disorder that exerts traction or presses 
upon the bladder, or it may be due to a relaxation of the perineum that 
permits the base of the bladder to sag. The pain of an acute inflammatory 
urethritis or cystitis may be very severe and be accompanied by straining 
and tenesmus. In extravesical inflammatory or other lesions that compress 
or draw upon the bladder the pain is ordinarily less acute in type. The 
frequent urination and discomfort incident to relaxation of the pelvic floor 
are greatly relieved when the patient assumes the prone position or when 
the displaced organs are supported in their normal position by the aid of 
a pessary. 

Pain during sexual intercourse is known as dyspareunia. A feeling of 
fulness and pressure or even of pain in the rectum may be caused by a 
rectocele. Difficulty in defecation may result from the fecal mass being 
driven toward the vaginal instead of toward the anal outlet. The patient is 
frequently unable to relieve herself until she pushes back the rectocele with 
her finger or liquefies the faeces by means of an enema. In extreme degrees 
of backward displacement of the uterus, when the body of the organ rests 
against the intestine, a sensation as of a foreign body in the rectum may be 
felt during defecation. 

A pelvic hematocele or a pelvic inflammatory mass may be associated with 
an intense and urgent desire to defecate. Pain during defecation is some- 
times present in prolapse of the ovary. Severe pain during and after defeca- 
tion is usually due to anal fissure, hemorrhoids, or perirectal abscess. 

Pain in the lower abdomen in the median line may be associated with 
relaxation of the pelvic floor, backward displacement of the uterus, uterine 
prolapse, and uterine or ovarian tumors filling the pelvis. 

Pain at the sides of the lower abdomen is most often associated with 
pelvic inflammatory disease or tubal and ovarian affections, as, for example, 
tubal pregnancy, cystic or prolapsed ovary, and small ovarian cysts. Pain 
due to lesions of the appendix is felt on the right, of the sigmoid on the 
left, and of the small intestine, kidney, and ureters on both sides. Pain 
due to displacement of the uterus, chronic metritis, congestion of the pelvic 
veins, and constipation is generally present in the lower abdomen on the 
left side. 

Pain in the sacral or lumbar region and in the buttocks or the back of 
the thighs may be associated with many gynecologic conditions or be due 
to lumbosacral or sacroiliac sprain. Backache of pelvic origin is especially 
characteristic of a relaxed pelvic floor and displacement of the uterus. 

Pain in the thighs may be caused by pressure of a tumor on the sciatic, 

. 7 



98 GYNECOLOGY 

obturator, or anterior crural nerves, or by inflammatory conditions within 
the pelvis. 

The character of the pain varies. Dull pain is most common in uterine 
enlargement (subinvolution, fibroid tumor) or displacement (descensus, 
prolapse), and in relaxation of the pelvic floor, and it may also be the result 
of pressure. When due to displacement, such pain is often associated with 
a dragging sensation, and when due to relaxation, with a want of support. 
Sharp stabbing pain in the pelvis is usually indicative of peritoneal involve- 
ment, as, for example, in salpingitis, ovaritis, appendicitis, peritonitis ; ex- 
cruciating pain of this type is present in rupture of a pregnant tube, twist- 
ing of the pedicle of an ovarian cyst or a fibroid tumor, intestinal 
obstruction, etc. 

Aching, neuralgic pain occurs in the areas of final distribution of those 
nerves which pass through the pelvis. This type of pain is common in the 
stage of carcinoma in which the cancer cells have actually invaded the 
nerve-sheaths. Dense inflammatory deposits in pelvic cellulitis and certain 
hard, fixed pelvic tumors produce similar symptoms, but they are usually 
of milder degree. 

Colicky pain in the pelvis is generally due to an effort of the uterus to 
expel a foreign body— the menstrual fluid in cervical stenosis ; a bit of 
placenta after labor or miscarriage ; an endometrial polyp or a pedunculated 
fibroid tumor. Repeated contractions of the overdistended ectopic tube pre- 
ceding tubal rupture or abortion may produce the most severe recurring 
pelvic cramps. Superficial burning and itching pains are accompaniments 
of acute inflammatory diseases of the vulva and vagina. 

The time at which pain occurs is of considerable significance. The pain 
due to displacements and relaxation subsides when the patient reclines in 
bed, and increases in severity when she goes about or works. 

Muscular or neuralgic pain is often worse at night or upon arising, and 
diminishes as movement limbers up the muscles and joints. 

Inflammatory pain is relieved to a certain extent by rest, since the in- 
flamed surfaces are kept apart and the muscular tension over the inflamed 
areas is reduced. Pain due to pelvic disease is almost invariably increased 
at the time of the menstrual periods. 

The pain of lumbosacral or sacroiliac sprains is augmented by certain 
movements that cause a strain upon the joints involved, and is diminished 
by immobilization of the parts. These pains are not always relieved by rest 
in the recumbent posture. After the patient goes to bed certain attitudes 
must often be assumed and pillows and the like be arranged in a certain 
way before relief will be obtained. 

Menstrual Symptoms. — The periodicity, duration, amount, and subjec- 
tive symptoms should be ascertained. 

Amenorrhcea may be an indication of occlusion of the genital tract, of im- 
perfect development, of lesions in the ovary, and of certain constitutional 
conditions that affect the general health. Amenorrhcea is physiologic 
during pregnancy and lactation, and is also caused by psychic impressions 
and changes of climate. Scanty menstruation is closely allied with amenor- 
rhcea. Suppression of the menstrual flow may follow exposure, wet feet, or 



HISTORY-TAKING AND SYMPTOMATOLOGY 99 

insufficient clothing of the lower extremities. Sea-baths, cold douches, and 
acute endometritis are also among the causes that produce amenorrhoea. 

Menorrhagia and metrorrhagia are conditions that are more or less simi- 
lar in origin. Any general state that predisposes to congestion of the pelvic 
blood-vessels, the acute infections, such as typhus or cholera, and secondary 
or tertiary syphilis are factors in the etiology. Among the local causes may 
be mentioned polyps, subinvolution, fibroid tumor, and carcinoma. 
Metrorrhagia is usually of more portentous significance than menorrhagia. 

Dysmenorrhea is a term which as usually applied signifies sharp, cramp-like 
pain in the lower abdomen, severe backache, and dull pain in the hips and ovarian 
region. Severe headache occurring only at the menstrual epoch has been 
considered by some a form of dysmenorrhea, but this theory is probably 
incorrect. The part that menstruation plays in the production of periodic 
headache is possibly due to the increase of blood pressure and nervous un- 
rest associated with the menstrual epoch. Headache has been ascribed to 
pelvic disorders, but these are rarely a primary cause. 2 More often they are 
a secondary factor, as witness the headache of intestinal stasis due to pelvic 
adhesions, the toxic headache that results from chronic pelvic infection, the 
anaemic headache associated with fibroid tumor, etc. 

When dysmenorrhea is a prominent feature the history should bring out 
the location and the character of the pain ; whether it occurs before, coinci- 
dent with, or after the flow, and how long it continues. Dysmenorrhea may 
be symptomatic of almost any pelvic lesion, or it may be significant of im- 
perfectly developed organs. It may also be purely nervous in type. 

In obstructive dysmenorrhea the pain is most severe before the flow 
appears. In chronic pelvic diseases other than uterine the pain is usually 
of a dull, heavy character, preceding the menstrual flow and gradually sub- 
siding as the flow is established. Dysmenorrhea associated with fibroid 
tumor or displacement of the uterus appears with the flow and continues 
throughout the period. The neuralgic form of dysmenorrhea may simulate 
any of the other types. 

Leucorrhoea. — The amount of the discharge may be judged by ascertain- 
ing whether a napkin must be worn to prevent soiling of the clothes. The 
consistency, color, and odor of the discharge may all be significant. 

A thick, mucous discharge of an extremely tenacious character usually 
comes from the cervix. If the discharge is mucopurulent, the presence of 
the remains of an old infectious process may be suspected. 

2 The belief that physiologic and pathologic states of the female generative organs 
often produce headache is widespread. Text-books mention dysmenorrhcea, " uterine 
disease," and diseases of the ovaries and even of the bladder as causes of headache, but 
no justification for this belief has yet been attempted. Headache is, of course, exceed- 
ingly common during menstruation, but so it is in eclampsia, although no one to-day 
would connect the eclamptic headache in any direct way with the| condition of the 
uterus. Toxemia of the puerperium and toxemia of the menstrual period constitute 
a much more possible though not a demonstrable hypothesis. 

Under his Table II, Cabot lists 13 gynecologic conditions as the etiologic factors in head- 
ache. In only two, dysmenorrhea and anteflexion, were headache, backache, and other 
hysteric or neurasthenic symptoms present more often than they were absent. In 181 
cases in which the pelvic organs were normal the headache, backache, etc., were present. 

In retropositions, for instance, headache, backache, etc., were absent in 44 cases, 
and present in 36. 



100 GYNECOLOGY 

A purulent discharge is symptomatic of one of the acute inflammatory or 
ulcerative lesions of the genital tract. As the process subsides the discharge 
becomes mucopurulent in character. 

Serous leucorrhoea or a thin watery discharge may accompany hyperplasia 
of the endometrium, and may occur early in the course of carcinoma of the 
body of the uterus, fibroid tumor, or sarcoma. A leucorrhoeal discharge with 
a putrid odor is significant of necrosis, and may be caused by a broken- 
down carcinoma, sloughing, necrotic polyp or fibroid, and decomposing 
retained secundines. 

Constipation. — Constipation is very common in women, and is especially 
marked in cases of retrodisplacement, fibroid tumor of the uterus, or im- 
pacted pelvic growths of any variety that encroach upon the rectum. It is 
also present in pelvic inflammatory diseases, both in the acute and in the 
chronic stage. 

Urinary Symptoms. — Frequency of urination is a common symptom of 
pelvic disorders, either of the bladder itself or of the structures in relation 
with it. In most cases of displacement of the uterus, relaxation of the pelvic 
floor, pelvic tumors, and pelvic inflammatory disease, frequent or painful 
micturition is a common finding. 

Frequent urination due to insufficiency of the pelvic floor is relieved by 
the recumbent posture. An inability completely to evacuate the bladder 
may exist in marked cases of cystocele, and in these cases the residual urine 
is often ammoniacal in nature. 

Diseases of the bladder and urethra as a cause of these symptoms can 
be excluded only after urinalysis or cystoscopic and urethroscopic exami- 
nation has been made. 

Gastro-intestinal Symptoms. — -A number of gastro-intestinal symptoms 
may be produced by adhesions between pelvic inflammatory masses and the 
intestines or omentum, and a large pelvic tumor encroaching upon the ab- 
dominal cavity may displace and compress the hollow viscera. Various 
degrees of ptosis also are associated at times with relaxation of the abdom- 
inal wall and displacement of the uterus. Not infrequently the appendix is 
involved coincident with pelvic inflammatory disease, and in patients over 
forty and fat, gall-stones may be present. The patient should invariably 
be questioned concerning any of the symptoms that might indicate the pres- 
ence of the lesions mentioned. Anorexia, a coated tongue, and a fetid breath 
may be the evidences of gastric, hepatic, and intestinal torpidity. Distress 
after eating, epigastric pain, and nausea and vomiting are not infrequently 
the symptoms of gall-stones. Gastric and duodenal ulcers must also be kept 
in mind, although they are not so frequent in this country as are gall-stones. 

Tympanites, cramp-like pain distributed more or less over the entire 
abdomen, obstinate constipation alternating with diarrhoea, impaired intes- 
tinal digestion, etc., may be indicative of ptosis, of adhesions of the intes- 
tines, or of chronic appendicitis. 

The patient should be questioned regarding previous attacks of pain 
that may have simulated appendicitis, the symptoms of which are more or 
less familiar to the laity. 



HISTORY-TAKING AND SYMPTOMATOLOGY 101 

Respiratory Symptoms. — Dyspnoea is at times produced by the pressure of 
a large intra-abdominal tumor. It is common in the anaemic subjects of 
fibroid tumor, and in the excessively obese. 

Circulatory Symptoms. — Palpitation of the heart may at times be asso- 
ciated with the anaemia and myocarditis incident to fibroid tumor, and with the 
pressure of large intra-abdominal tumors or collections of fluid. The pres- 
sure of an intrapelvic tumor may cause oedema of the ankles or of the entire 
lower extremities, or it may produce varicosities in the saphenous veins. 

Nervous Manifestations. — Headache is a not uncommon symptom, and 
in many cases, especially in those suffering from nerve exhaustion, the dis- 
tress is occipital and is accompanied by pain along the upper part of the 
spine. Headache is rarely due primarily to pelvic trouble, but may be 
caused indirectly by intestinal stasis or inflammatory diseases and their 
secondary toxaemias. The frequency with which a predisposition to headache 
is associated with neurasthenia and psychasthenia, or merely with nervous tem- 
perament, is significant of the close relationship that exists between this 
disorder and an unstable nervous organization. Diseases of the eye and of 
the nasofrontal sinuses, gastritis, etc., are certainly more frequent causes than 
the pelvic disturbance itself. Headache may be hereditary, as, e.g., in 
migraine, or it may be due to syphilis or to brain tumor. Headache occur- 
ring chiefly at the menstrual periods is usually a manifestation of the in- 
creased vasomotor and nervous impulses present at that time. 

Many patients who exhibit symptoms simulating those of pelvic dis- 
orders are neurasthenic or hysteric subjects. Vertigo and depression of 
spirits may accompany an asthenic general condition, and may be espe- 
cially marked at the menstrual periods or at the time of the menopause. A 
woman may be subject to many nervous conditions that vary all the way 
from eccentricity to an actual neurosis. Eccentricity may be hereditary or 
due to the peculiarities of environment and the habits of the individual. 
Simple instability of the nervous system (nervousness) may be due to anxiety, 
prolonged and uncongenial work, distressing circumstances, sudden calamities, 
shock, and anything that will upset or unbalance the nervous equilibrium. Ner- 
vous symptoms are particularly marked at the menstrual periods. 

Psychasthenia, an unbalancing of the mind, may be evidenced by in- 
stability of purpose, emotional outbreaks, depression of spirits, and fixed 
ideas of unworthiness, persecution, and marital infidelity. Mental depres- 
sion is not uncommon at the menstrual periods. It is only by close question- 
ing and possibly from the information secured from friends that the physician 
will be enabled to decide between the imaginary and the real in the patient's 
recital of drudgery, blighted affections, etc. It may at times be extremely 
difficult to ascertain the real cause of the depression and nervous exhaus- 
tion. Even the most intelligent will often, from a sense of shame, conceal 
the important causative factors of their nervous unrest and depression. 

General Health. — The present condition should be compared with that 
of earlier years. The patient who has never been robust is more likely to 
be suffering from constitutional illness or defects than is the one whose 
indisposition dates from a certain epoch, such as puberty, marriage, labor, etc. 



102 GYNECOLOGY 



BIBLIOGRAPHY 



Butler, G. R. : The Diagnostics of Internal Medicine. Appleton, New York, 191 1, 3d ed. 

Cabot, R. C. : Differential Diagnosis. Saunders, Phila., 1911. 

Chapin, H. D., and Pisek, G. R. : Diseases of Infants and Children. Wood and Co., New 

York, 191 1, 2nd ed. 
Dercum, C. T. : " The Nervous Disorders in Women Simulating Pelvic Disease. An 

Analysis of 591 Cases." Jour. Amer. Med. Asso., March 13, 1909, p. 848. 
Holt, L. E. : Diseases of Infancy and Childhood. Appleton, New York, 1908, 4th ed. 
Kelly, H. A., and Hurden, E. : " Operations Before Puberty," Chap, xxv, Kelly-Noble, 

Gynecology, vol. i, Phila., Saunders, 1907. 
Kerr, C. B. : Infectious Diseases. Oxford Med. Pub. Co., London, 1909. 
Kisch, E. H. : Das Geschlechtsleben des W>ibes. Urban and Schwarzenburg, Vienna, 1907. 
Lebedinsky : " tiber pathologisch-anatomische Veranderungen an dem Eierstocke bei 

Scharlach." Centralbl. f. Gynak., 1877, i, no. 
Massin, W. N. : " Zur Frage iiber Endometritis bei akuter infectioser allegemein Erkrank- 

ungen." Arch. f. Gynak., 1891, xi, 146. 
Noble, C. A. : " The Constitutional Factor in Gynecology." Trans. Amer. Gyn. Soc, vol. 

xli, 1916, p. 656. 
Osler, W. : Principles and Practice of Medicine. Appleton, New York, 1912, 8th ed. 
Stengel, A., and Fox, H. : Text-Book on Pathology. Saunders, Phila., 1915. 
Tait, Lawson : Pathology and Treatment of Diseases of the Ovaries. Cornish, Birming- 
ham, 1883. 
Thorn, Wilhelm : " Beitrag zur Lehre von der Atrophia Uteri." Zeitschr. f . Geburtsh. u. 

Gynak, Bd. xvi, S. 57. 
Veit, J. : Handbuch der Gynakologie. Bergemann, Wiesbaden, 1897. 



CHAPTER VII 
GENERAL PHYSICAL EXAMINATION 

The diagnosis is based to a certain extent upon the results of physical 
examination. Much stress may be placed upon the importance of ascertain- 
ing the general physical and mental condition of the patient. Not infre- 
quently the patient has undergone a thorough physical examination before 
she is seen by the gynecologist. When a careful general investigation has 
not previously been made, it should be conducted in conjunction with the 
gynecologic examination. The assistance of an internist, an alienist, or 
possibly a specialist in diseases of the eye, ear, nose, and throat may be 
required in order to interpret correctly the symptoms presented and indicate 
the proper treatment. 

The gynecologist should note the general appearance of the patient — the 
build, whether emaciated, well rounded, or excessively fat ; the carriage, 
whether erect or stooped ; the color, whether it be the glow of health, the 
pallor of anaemia, or the yellowish tint of cachexia ; the facial expression, 
whether it indicates buoyancy of spirits or mental anxiety and depression ; 
the weazened face of the woman suffering from an ovarian cyst, or the per- 
turbed, anxious expression of one stricken with peritonitis. 

TEMPERATURE 

An elevation of temperature accompanies most of the acute infections of 
the pelvic organs. It may also be present as the result of the absorption of 
ferments or toxins from blood-clots and traumatized or necrotic tissue. The 
height of the temperature and the variations in its course are dependent 
upon the nature of the underlying lesion and the resisting powers of the 
individual. The temperature in gonococcus and tuberculous infections is 
lower than in infections due to the streptococcus, staphylococcus, colon 
bacillus, bacillus pyocyaneus, bacillus diphtheria?, and other pyogenic organ- 
isms. Infections of the lower genital tract, vulva, urethrovaginal glands, 
etc., are less likely to be accompanied by high fever than are those of the 
cervix, endometrium, uterine wall, cellular tissue, tube, ovary, and pelvic 
peritoneum. Rapidly growing or disintegrating malignant growths are 
accompanied with pyrexia. Necrotic decidua or retained placenta, slough- 
ing cervical polypi, or submucous myomata usually give rise to fever. In 
tubal pregnancy, pelvic hematocele, ovarian cyst, or pedunculated fibroid tumor 
with twisted pedicle the temperature is, as a rule, slightly elevated from 
absorption of fibrin ferment, even though no infection has occurred. 

The elevation of temperature accompanying pelvic disorders is usually 
continuous in type ; but if the progress of the disease is arrested and there 
is a localized collection of pus, it becomes remittent. If very little or no pus is 
formed and the septic products of the infection are absorbed, the temperature 
gradually recedes to normal. In the acute pyelitis of pregnancy and in 
acute phlebitis or cellulitis following abortion or labor, the temperature is 

103 



104 GYNECOLOGY 

remittent or intermittent in type from the beginning, and is accompanied 
by chills. Chills and high remittent fever are characteristic of the sudden 
entrance into the blood of large amounts of septic products, as in strepto- 
coccus infections of the uterine wall, the veins or lymphatics of the broad 
ligament, or the pelvic peritoneum. 

The elevation of temperature accompanying pure gonorrhceal pelvic in- 
flammatory disease, as a rule, subsides as the disorder disappears in the 
course of a week or ten days. 

The temperature of streptococcus infections is more apt to continue for 
a longer period, and to be subject to repeated exacerbations, finally reaching 
the normal or becoming intermittent if an abscess forms. 

CIRCULATION 

Pulse. — The pulse-rate is normally a little higher in women than in men. In 
febrile conditions the frequency is increased from eight to ten beats for each 
degree of temperature above the normal. The degree of acceleration of the 
pulse in direct ratio to the rise in temperature is often an indication of the 
virulence of the toxic products that are being absorbed. Thus a pulse-rate 
relatively lower than the temperature is an indication of a milder toxin, 
whereas a relatively more rapid increase is an indication of a more virulent 
toxic process. The full, high-tension pulse marks the strong reactions ; the 
weak, low-tension pulse indicates an inability to react ; the former indicates 
the antagonism of the economy to the toxic products, whereas the latter 
points to an overwhelming of the economy by the toxic products. Coldness 
of the extremities with a rapid, low-tension pulse and high fever are indica- 
tions of approaching dissolution from absorption of septic products. 

Rapid pulse unaccompanied by fever is observed in conditions in which 
excruciating pain is present, as, for instance, in twisting of the pedicle of an 
ovarian cyst or a pedunculated fibroid or during the passing of a renal cal^ 
cuius. In these conditions the patient is often in a state of collapse, and the 
temperature may be subnormal. 

An increased pulse-rate and a subnormal temperature are seen after 
acute hemorrhage, either external, as in miscarriage with profuse bleeding, 
or internal, as in a ruptured pregnant tube with free intraperitoneal hemor- 
rhage. The pulse is always of low tension in cases of hemorrhage. The 
rapid pulse of hemorrhage is not accompanied by dyspnoea until an extreme 
degree is reached. The pulse may be increased as the result of repeated 
hemorrhages occurring over a long period of time, after which anaemia and 
myocardial changes finally supervene, as in fibroid tumor. The rate may also be 
increased by pressure on the diaphragm exerted by abdominal tumors or ascites. 

An increase in pulse-rate may also occur in the general disorders accom- 
panying pelvic disease, such as hyperthyroidism, intrinsic cardiac disease, etc. 

A sudden increase of the pulse-rate followed by a rapid failure is ob- 
served in pulmonary embolism. 

The blood- pressure becomes higher with age. It is increased by arterio- 
sclerosis, cirrhosis of the liver, interstitial nephritis, obesity, etc., and is 
diminished by anaemia, hemorrhage, and septic toxaemia. 



GENERAL PHYSICAL EXAMINATION 105 

After prolonged surgical operations, and in those attended with much 
loss of blood, the blood-pressure is subnormal. 

The significance of abnormalities in the blood-pressure and their bear- 
ing on prognosis in operations will be dealt with in Chapter XXXV. 

Heart. — Cardiac insufficiency may be responsible for menorrhagia, 
metrorrhagia, leucorrhcea, and other symptoms of chronic pelvic congestion. 
The pelvic condition that appears most frequently to produce cardiac disorders 
is fibroid tumor of the uterus. Murmurs, dilatation and hypertrophy, and 
fatty infiltration may occur. These are all due largely to anaemia, and if the 
fibroid tumor is removed before permanent changes have taken place, the 
heart may again become normal. When the tumor is of long standing, a 
form of myocarditis results ending in brown atrophy. The heart may be 
displaced upward and to the left by distention of the abdomen, as in ascites 
and large ovarian cysts. 

Epigastric pulsation of the abdominal aorta is a common cause of com- 
plaint in neurotic females and at the climacteric. Functional cardiac dis- 
turbances, manifested by palpitation, faintness, pallor, rapid breathing, etc., 
may be observed at puberty, at the recurring menstrual periods, during 
coitus, at the climacteric, etc. They are seen chiefly in those of unstable 
nervous temperament. 

Engorgement of the veins of the lower extremities, when bilateral, is 
frequently due to some general disturbance of the circulatory system ; when 
unilateral, it is due to obstruction of some or of all of the tributaries of the 
iliac veins on the affected side ; this may take the form of thrombophlebitis, 
carcinomatous infiltration, or compression. 

The effect of cardiac conditions on the prognosis of operations is de- 
scribed in Chapter XXXV. 

RESPIRATION 

Respiratory Rate. — An increase in the respiratory rate in febrile conditions 
is in direct proportion to the elevation of the temperature and the frequency of the 
pulse. It may, however, occur independently of either, or with a rapid 
pulse alone, in anaemia, myocardial affections, and comoression or displacement 
of the lungs by enormous distentions of the abdomen, as from tumors or 
ascites. Disproportionate acceleration of the respiratory rate is suggestive 
of intrinsic pulmonary disease — e.g., tuberculosis, emphysema, asthma. When 
such disease really exists, other indications of it. notably cough and expec- 
toration, are generally present. Rapid, sighing respirations are observed 
in acute profuse hemorrhage when the loss of blood has been great and 
dissolution is impending. Severe septic toxaemias may greatly augment the 
respiratory rate in oedema of the lungs and cardiac dilatation. Metastasis of 
chorio-epithelioma of the pelvic organs to the lungs is accompanied by 
pain, increase of respiration, cough, and bloody expectoration. Pulmon- 
ary embolism is marked by sudden and exaggerated dyspnoea. 

The normal type of respiration that is a combination of costal and abdom- 
inal motion is changed to the costal variety, or partly so, by conditions that 
produce large distentions of the abdomen, as tumors, ascites, tympanites, etc. 

The bearing of pulmonary diseases on the prognosis of surgical opera- 
tions is dealt with in Chapter XXXVI. 



106 GYNECOLOGY 

Lungs. — Chronic bronchitis, emphysema, or asthma with cough may be 
a contributing cause of descensus uteri or incontinence of urine. A tuber- 
culous pulmonary lesion may be the initial focus of an inflammatory disease 
of the same type in the pelvis. 

Among the pulmonary affections following operations may be men- 
tioned bronchitis, pneumonia, pleurisy, and acute pulmonary oedema. 

BLOOD 

Blood Count. — A complete examination of the blood is always desir- 
able, for two purposes: First, to determine whether any form of anaemia is 
present, the blood picture showing, to a certain extent, at least, the general 
strength and resistance of the patient ; and, secondly, to ascertain whether 
there is evidence of any septic process, as may be indicated by an increase 
in the number of leucocytes. 

Leucocytosis is usually present in pelvic inflammation. It is less marked 
on the whole, in gonorrhoeal salpingitis (12,000-15,000) than in acute appen- 
dicitis (15,000-20,000). It is more marked in puerperal or post-abortal infec- 
tion than in either (20,000-30,000). 

The increase in the white blood-cells in infectious processes affects 
especially the polynuclear cells. A disproportionate increase of the poly- 
nuclear cells over the total leucocyte count occurs in suppurative and 
gangrenous conditions. 

The percentage of polynuclear cells, as shown by a differential count, 
may be taken as an index of the severity of the infection, as well as of the 
resisting power of the individual. As leucocytosis is an indication of re- 
sistance on the part of the patient, a steady increase usually points to an 
increasing lesion with increasing resistance, whereas a decrease indicates 
a subsiding or a localizing disorder. It must not be forgotten, however, that 
the white blood count may be low notwithstanding the presence of a serious 
and widespread local lesion if the patient is in poor condition and the 
natural defenses of the body are weak. 1 

The anaemias encountered in gynecologic cases are, in a large majority of 
instances, those known as secondary, and result from hemorrhage or toxaemia 
or from both. In acute secondary anaemia the red blood-cells and the haemo- 
globin are reduced proportionately, whereas the white cells are relatively 
increased. In chronic secondary anaemia without toxaemia all the cells are 
proportionately reduced. 

In secondary anaemia with toxaemia (hemorrhage plus infection) the red 
cells and the haemoglobin are diminished, whereas the white cells are proportion- 
ately and absolutely increased. In that form of anaemia known as chlorosis, 
which is most frequent in young women and interferes with the establish- 
ment and course of menstruation, other changes in the blood occur. The 
haemoglobin is disproportionately diminished, and the red blood-cells may 
exhibit abortive or degenerate and malformed types. 

1 The polynuclear cells represent the phagocytic powers, and they are therefore in- 
creased during the acute stage of an infectious process in proportion to its severity and 
to the resistance of the individual. When the acute process has been arrested a diminution 
in the relative proportion of polynuclear cells and an increase in the relative proportion 
of lymphocytes occur. 



GENERAL PHYSICAL EXAMINATION 107 

Blood Culture. — A diagnosis of bacteriaemia can be made with certainty 
only when the organisms in the blood are identified. As a rule, the clinical 
evidences of bacterisemia are sufficient for all practical purposes, so that cul- 
tures need not be taken. As an aid to prognosis, or for the selection or 
preparation of an antagonistic serum or vaccine, the isolation of organisms 
from the blood may be extremely useful. The presence of the streptococcus 
in the blood renders the prognosis grave, and is an indication for the injec- 
tion of antistreptococcic serum. These organisms should always be demon- 
strated in the blood before the administration of antistreptococcic serum is 
begun. The staphylococcus and the colon bacillus may also be recovered 
from the blood. Repeated positive findings are necessary in order that faults in 
the technic may be excluded. An antistaphylococcic serum and an anti-colon 
serum are now on the market. (See Chapter XXI.) 

Wassermann Reaction. — This reaction or test for syphilis is dependent 
upon the formation, in the blood of an infected person, of a specific anti- 
body. This antibody has the power of combining with the complement 
(guinea-pig serum) in the Bordet-Gengou haemolytic system and rendering 
it inactive. This system consists of antigen (solution of syphilitic liver), 
complement (guinea-pig serum), and suspected serum in certain definite 
amounts. After incubation for a short time — usually one-half to one hour — 
sheep's blood-corpuscles and the haemolytic amboceptor are added and the 
whole again incubated. If the complement has been fixed by the antibody 
complement-fixing substance during the first incubation, it cannot combine 
with the other elements during the second incubation and cause a solution 
of the corpuscles, or haemolysis. A positive reaction is indicated by the ab- 
sence of, or a slight degree of, haemolysis. The reaction is not absolutely 
specific ; thus it has been found positive in f ramboesia, leprosy, and yaws. It 
is, however, the most reliable test at our command in making a diagnosis of 
a syphilitic infection. 

Abderhalden Serum Test. — The Abderhalden serum test was said to be 
of value in making the diagnosis of pregnancy. The test depends upon the 
appearance in the blood of ferments whose function it is to destroy foreign 
cells or their products invading the circulation. These invading elements 
in pregnancy are known as the syncytial cells. Owing to the elaborate 
detail of the technic and the uncertainty of the result, the test was not adopted 
generally for practical purposes. In view of the diverse and conflicting results 
obtained by various observers, the value of the test is doubtful. A positive 
reaction is of little value, since it may be found in conditions other than 
pregnancy, notably in carcinoma. A negative finding in a woman suspected 
of being pregnant is of considerable importance, since it is an indication of a 
lack of the specific ferments which are normally formed for the purpose of 
destroying the syncytial cells. 

Complement-fixation Test for Gonorrhoea. — This test depends upon the 
fixation of a complement by a specific antigen (gonococci), and a specific 
antibody (in the patient's serum), with a resulting inhibition of haemolysis 
or positive reaction. 

Schwartz and McNeil, whose work along this line has been most con- 
vincing, employed a polyvalent antigen (12 strains of gonococci). They 



108 GYNECOLOGY 

used both antisheep and antihuman hemolytic sera, and followed the technic 
laid down in the well-known Wassermann test for syphilis and in Noguchi's 
modification of this test. 

A positive reaction is rarely attained until the third or fourth week of the 
disease. The reaction persists for seven or eight weeks after the patient 
has recovered. If only the anterior urethra is involved no reaction may 
be elicited. 

In adult women the test is seldom positive until the infection has 
reached the cervical canal. In little children with vulvovaginitis positive 
reactions occur early. This may be explained by the more delicate nature of 
the vulvar and vaginal mucosa and the increased absorption therefrom. 

A positive reaction may be regarded as evidence of gonococcus infection, but 
a negative reaction does not necessarily exclude the disease (Kolmer). 

The test is of especial value to the gynecologist, since it is often difficult 
to demonstrate the existence of chronic gonorrhoea in women by the discovery 
of the gonococcus in smears or by cultures. 

Lespinasse and Wolff believe the test to be of value in clearing up the 
etiology of certain obscure lesions — whether, for example, a certain leucor- 
rhoeal discharge is gonorrhceal or non-gonorrhceal ; in differentiating gonorrhoea 
of the tubes from other pelvic lesions ; in explaining the occurrence of puer- 
peral fever in cases where aseptic precautions have been observed. 

Thomas and Ivy point out that in the acute stage of the disease, when 
the fixation test is negative, it is usually easy to demonstrate the presence 
of the gonococcus bacteriologically, whereas in the chronic stage, when 
bacteriologic methods often fail entirely, the fixation test shows a positive reac- 
tion. The two methods of examination are, therefore, in a sense complementary. 

Method of Obtaining Blood for Serum Tests. — Blood for cultures and 
for Wassermann reactions, the Abderhalden test, and the complement- 
fixation test for gonorrhoea may be obtained by puncturing a vein. The skin 
over the median cephalic or basilic vein is painted with tincture of iodine. 
The vein is rendered prominent by the application of a moderately tight 
bandage about the upper arm. For blood cultures a glass syringe of 10 c.c. 
capacity, to which is fitted a sharp-pointed needle, is used. The needle is 
passed obliquely into the vein, and the blood obtained by slowly withdraw- 
ing the piston. The bandage should be removed before the needle is with- 
drawn. The blood is immediately injected into bouillon or agar-agar. Ex- 
treme care should be taken to prevent contamination, and all the instruments 
and utensils must be absolutely sterile. For the complement-fixation and 
other tests the blood may be allowed to drop directly from the needle into a 
sterile test-tube ; from 5 to 10 c.c. are required. The site of the puncture may 
be sealed w r ith cotton and collodion. 

URINE 

Urinalysis. — A study of the urinary excretion discloses the condition of 
the kidneys. As the term is commonly employed, urinalysis comprises a 
chemical and microscopic examination of the urine. A complete investiga- 
tion of the urinary function goes further and includes the determination of 
the total amount of urine excreted in twenty-four hours, and the ability of 



GENERAL PHYSICAL EXAMINATION 109 

the kidneys to excrete certain substances that test their functional activity. In 
order to differentiate between the functional activity of the right and of the 
left kidney it is necessary to employ cystoscopy and catheterization of the 
ureters, which are dealt with in Chapter IX. We will confine ourselves 
here to a general survey of a study of the urine, such as is required in the 
diagnosis and treatment of diseases of the generative organs. 

A most important point to be emphasized at the beginning, and one that 
is frequently overlooked, is the fact that the discovery of certain abnormal 
constituents in the urine has no diagnostic value unless the specimen has 
been removed directly from the bladder with the aid of a catheter. If, for 
example, a voided specimen is found to contain albumin, pus, or blood, this 
is no indication that the bladder or upper urinary tract is the seat of disease, 
for the chemical or microscopic findings may be due to contamination with 
blood or pus escaping from the vaginal orifice. L T nless the examination of 
a voided specimen is entirely negative, the result has no value. If, there- 
fore, the voided specimen contains any abnormal constituents — and in a 
majority of patients coming under a phyiscian's care this will be the case 
unless the vagina and vulva have been douched with sterile water just 
before the bladder is emptied — a catheterized specimen will be required in 
order to make accurate deductions. 

The reaction of the urine is usually faintly acid. Alkalinity of a freshly 
obtained specimen indicates urinary stagnation and ammoniacal decomposi- 
tion or the undue ingestion of alkalies. 

A low specific gravity may be indicative of an abnormally large inhibi- 
tion of fluids or of a faulty eliminative power of the kidneys. 

A high specific gravity may indicate an excess of solids and a deficiency 
of fluids and of certain abnormal constituents, notably sugar. 

The urine may give off an ammoniacal odor as the result of stagnation 
and decomposition, as in cases of large cystocele. An offensive odor, not 
unlike that of decomposing fish, is present in chronic infections of the urinary 
tract associated with bacteriuria. When there is a fistulous communication 
between the intestinal and urinary tracts the urine takes on a fecal odor. 
The urinary fluid may be cloudy from an excess of phosphates, urates, or 
oxalates. It may be pink or reddish in color from the presence of urates, uric 
acid, or blood, yellow from contamination with bile-pigment ; black from the 
presence of old blood, and milky from admixture with pus. 

It may contain macroscopic shreds of pus, long, worm-like clots of blood 
indicative of renal or ureteral bleeding, or the finely granular, brick-dust 
sediment of uric acid. 

Albuminuria may point to interstitial or parenchymatous nephritis, 
pyelitis, ureteritis, or cystitis. 

Pus in the urine may be found in any of the diseases associated with 
suppuration of the kidney, ureter, or bladder ; if the specimen has not been 
obtained by catheterization, but was voided, diseases associated with sup- 
puration of the urethra, ovaries, tubes, uterus, vagina, and vulva may be 
included in the summary of possible explanatory lesions. 

Blood may be found in the urine in any disease of the urinary tract 
accompanied by trauma to the mucosa, fracture of friable masses, or destruc- 



110 GYNECOLOGY 

tion of tissue. Among the most frequent of these conditions should be 
mentioned calculus, tuberculosis, and new growths of the kidney or bladder. 

Casts represent the albuminous products that have coagulated in the 
tubules of the kidney and were later expelled in the form of small cylinders. 

Hyaline casts in the urine are an indication of altered excretion and of 
the presence of albuminous products. 

Granular casts, blood casts or pus casts in the urine signify respectively 
the presence in the kidney of some process that causes destruction of the 
epithelium of the kidney tubules, a kidney disorder associated with hemor- 
rhage into the tubules, or a suppurative disease of the kidney. 

The urine as it is excreted from the kidney tubules may contain albumin, or 
the albumin may be derived later from the pus or blood that is mixed with it. 
Goldberg found that from 80,000 to 100,000 pus-cells per cubic centimeter 
of urine will produce 1 per cent, albumin. 

Albuminuria may be due to pressure on the renal veins, as from the 
pregnant uterus or from a tumor. It may also be due to fever and to the 
absorption of toxins in infectious diseases. It may likewise be caused by an 
excess of proteids in the diet, prolonged physical exercise, and alcoholic excesses. 

Glycosuria is usually indicative of diabetes, and may explain a per- 
sistent pruritus vulvae. Temporary glycosuria may be observed as a conse- 
quence of the increased consumption of sweets. 

Acetone may be found in the urine of patients suffering from the per- 
nicious vomiting of pregnancy, ectopic gestation, continued fever, and 
acidosis. It is significant of acid intoxication. Diacetic acid may be found in 
the urine of patients suffering from diabetes and acidosis. Its presence also 
is indicative of acid intoxication. 

Indican may be found in the urine of patients exhibiting conditions of 
diminished or inhibited peristalsis, constipation, peritonitis, or ptosis. It 
signifies that intestinal decomposition and putrefaction have occurred. 

In addition to these chemical and microscopic tests the sufficiency of the 
kidneys is indicated in a general way by the total amount of urine excreted 
in twenty-four hours. This normally averages from 1200 to 1600 c.c. (40 to 
60 ounces). It is increased by cold, when perspiration is diminished, and 
decreased by heat, when perspiration is excessive. 

When more detailed information concerning the kidney function is 
desired, the tests described in Chapter IX should be undertaken. 

Bacteriologic Examination of the Urine in General. — The specimen of 
urine to be examined may be centrifugalized and a drop of the sediment 
placed on a slide together with a drop or two of Gruebler's methylene-blue 
solution. This will demonstrate the presence of pus, blood, and epithelium, 
as well as of bacteria. Smears may also be made from the sediment, and 
allowed to dry; they are fixed and stained with methylene-blue or gentian 
violet for the ordinary bacteria, and by Gabbett's method for acid-fast bacilli. 
It is impossible to distinguish absolutely between the tubercle bacillus and 
other acid-fast bacilli. A point in the differentiation, however, is the fact 
that the tubercle bacilli are found at the periphery of clumps of degenerated 



GENERAL PHYSICAL EXAMINATION 111 

into a field of pus-cells. For positive identification the guinea-pig test should 
be made. Cultures may be made of the urine taken from the bladder or kidney 
by urethral or ureteral catheterization. The urine must be collected in 
sterile test-tubes which are then plugged with sterile corks and covered 
with rubber caps. The urine is transferred to the appropriate culture- 
i medium by the bacteriologist. 

Recognition of Tubercle Bacillus by Guinea-pig Inoculation. — The 
method of Bloch is the most rapid and satisfactory. A twenty-four hour 
specimen of urine is collected in a large sterile bottle. No preservative is 
added. The specimen is centrifugalized for from two to four hours ; about 
10 c.c. of the lower portion is taken. This sediment is shaken with 5 ex. of 
sterile water, to make a suspension. Two healthy, normal guinea-pigs are 
inoculated. The inguinal glands of the animals are slightly injured by 
pressing and rolling them between the forefinger and thumb for a few 
moments prior to making the inoculation. About 2.5 c.c. of the prepared 
suspension is injected unheated into each animal subcutaneously in the inguinal 
region, below the glands. The glands are then again subjected to pressure 
for a few minutes, and this is repeated on the two succeeding days. At the 
end of ten days one of the animals is chloroformed, and the inguinal glands on 
the injected side are removed and sectioned and stained for the tubercle bacillus ; 
or the glands may be finely macerated, pressed between two slides, and 
fixed and stained. In a majority of positive cases the tubercle bacillus is 
immediately discovered ; if it is not, every part of the inguinal tissue is 
stained and subjected to examination. The other animal is kept for six 
weeks and is then examined for general tuberculosis. 

BIBLIOGRAPHY 

Bloch, A. : " Der rascher Nachweis des Tuberkelbacillus im Urin durch den Tierversuch." 
Berl. klin. Wchnschr., 1907, vol. xliv. p. 511. 

Butler, G. R. : The Diagnostics of Internal Medicine, 3rd ed. Appleton, New York, 1910. 

Dercum, C. T. : "The Nervous Disorders in Women Simulating Pelvic Disease." 
J. A. M. A., vol. Hi, p. 848. 

Gibson, C. L. : " The Value of the Differential Leucocyte Count in Acute Surgical Disease." 
Ann. Surg., 1906, vol. xliii, p. 485. 

Keene, F. E., and Laird, J. L. : " The Diagnosis of Tuberculosis of the Kidney." Am. 
Jour. Med. Sc, 1913, vol. cxlvi, p. 352. 

Kolmer, J. A.: Infection, Immunity and Specific Therapy. Saunders, Phila., 1915, p. 483. 

Lespinasse, V. D., and Wolff, M. : " The Clinical Value of the Gonorrhea Complement- 
Fixation Test," 111. Med. Jour., 1913. vol. xxiii, p. 26. 

Musser, J. H. : Medical Diagnosis. Lea and Febiger, Phila., 1913. 

Owen, R. T., and Snure, H. : "The Complement-Fixation Test in the Diagnosis of Gon- 
orrhoea." Jour. Mich. State Med. Soc, 1913, vol. xii, p. 247. 

Schwartz, Hans J., and McNeil, A. : " The Complement-Fixation Test in the Diagnosis 
of Gonococcic Infections." Am. J. Med. Sci., 1911, vol. cxli. p. 693; Ibid. : "Further 
Experiences with the Complement-Fixation Test in the Diagnosis of Gonococcus 
Infection of the Genito-Urinary Tract in the Male and Female." Am. J. Med. Sci., 
1912, vol. cxliv, p. 815. 

Simon, C. E. : Clinical Diagnosis. Lea and Febiger, Phila., 191 1, 7th ed., p. 46. 

Stengel, A., and Fox, H. : Text-Book of Pathology. Saunders, Phila., 1915. 

Thomas, B. A., and Ivy, R. H. : " The Gonococcus Complement-Fixation Test and Analysis 
of Results from Its Use." Arch. Int. Med., 1914, vol. xiii, p. 143. 

Warden, C. C, and Schmidt, L. E. : "Gonococcus Complement-Fixation ; a New Lipoid 
Antigen," Jour, of Lab. and Clin. Med. 1916, vol. i, p. 333. 

Winter, G., and Ruge, C. : Gynecological Diagnosis, edited by J. G. Clark. Lippincott, 
Phila., 1912. 



CHAPTER VIII 
EXAMINATION OF THE PELVIS AND ABDOMEN 

In making the local physical examination both the pelvis and the abdomen 
should be included. The most satisfactory results are obtained with the 
patient in a conscious state. 

Examination Under Anaesthesia. — When, because of rigid abdominal 
walls, excessive adiposity, sensitiveness, or fear, a pelvic examination can- 
not be satisfactorily conducted, complete anaesthesia is advisable in order to 




Fig. 99. — Diagram showing different positions of uterus with full bladder Of 

rectum or both. Illustrates importance of having these organs empty at time 

of pelvic examination. (.4) normal position of uterus; (B) position with bladder 

and rectum filled; (C) position of uterus with bladder alone distended. 

rule out or to confirm the existence of a suspected lesion. As a rule, it is de- 
sirable, prior to examination, to obtain the permission of the patient to make 
such operative correction as the existing conditions may demand. 

Examination under anaesthesia is most frequently required in young vir- 
ginal women. In any case in which an abnormality is suspected and a 
bimanual rectal examination is unsatisfactory, examination under anaesthesia 
should be advised without delay. In young virginal women vaginal examination, 
except under anaesthesia, should be avoided. Every condition requiring 
operative correction should receive attention at this time, so that nothing 
112 



EXAMINATION OF THE PELVIS AND ABDOMEN 



113 



further will be required later. (See Relation of Neuroses to Pelvic 
Disease, Chapter XXXIV.) 

Ether is the safest and most satisfactory anaesthetic to use for purposes of 
examination. Nitrous oxide does not give complete relaxation. If the patient 
is tuberculous or if the kidneys are seriously damaged, chloroform is to 
be preferred. 

Preparation for Examination. — As a rule, some preparation for examina- 
tion is required. Most patients who have leucorrhcea will take a vaginal 
douche before consulting a gynecologist. This often destroys important 
evidence, and it may be necessary to direct the patient to omit douches for 
several days and then return. The urine should be held as long as possible 
before the examination, so that the physician can ascertain whether or not 
Skene's tubules or the urethra contain pus. 

The bladder and the bowel should be emptied before bimanual examina- 
tion (Figs. 99 and ioo). This may be impracticable at the first consultation, 
for an evacuation of the bowel may involve 
considerable delay. For that reason, if pos- 
sible, the patient may be instructed to take a 
purgative the night before and an enema on 
the morning of the examination. 

When a patient appears for examination 
and is insufficiently prepared, a second visit, 
with suitable preparation, should be ordered. 

To facilitate a gynecologic examination a 
number of positions have been used that 
render the parts more readily accessible to in- 
spection and simplify certain manceuvers that 
would otherwise be difficult. 

The Dorsal Position (Fig. 101). — The dor- 
sal position is the one commonly employed in 
bimanual palpation of the pelvic organs, in- 
spection of the external genitalia, and local applications to the urethra, vulva, 
vagina, and cervix. 

The patient lies upon her back with the thighs well flexed upon the 
abdomen and the knees widely separated. The legs are flexed on the thighs 
and the feet are held either by stirrups suspended from upright rods or by 
foot-rests at the end of the examining table. A portable stirrup or leg- 
holder has been devised by Robb, which facilitates examinations or opera- 
tions in the dorsal position, and is especially adapted to procedures at home. 
The buttocks should project slightly over the edge of the table. If neces- 
sary, the patient can be examined in bed. She should lie across it with her 
buttocks resting on the edge, the shoulders and head elevated by a pillow, 
the knees widely separated, drawn upward, and supported by assistants. 

When the feet are held in stirrups, they should not be widely separated. 
There will then be more separation of the knees than if the feet were held 
widely apart; the thighs will rotate outward, and the fullest relaxation of 
the lower abdominal wall will thus be secured. 

The dorsal position is modified at times for the purpose of making 
8 




Fig. ioo. — Position of uterus, with dis- 
tended bladder and rectum. 



114 



GYNECOLOGY 



bimanual palpation by slightly elevating the trunk; the examining table 
may be inclined somewhat toward the foot, or, if an examining chair is 
used, the patient is placed in a semi-sitting position. The dorsal position 
is that commonly used in performing plastic operations upon the cervix 
and the perineum. 

Knee-chest Position (Fig. 102). — In assuming this position the patient is 
ordered to kneel upon the table, spreading the arms out on each side and 




Fig. 10 1. — Dorsal or lithotomy position. 



flexing the elbows. The face should be turned to one side. The thighs 
must be vertical, the chest must rest upon the table, the spinal column 
must be relaxed, and the lumbar curve be exaggerated. 

The knee-chest position is useful principally in the treatment of retro- 
version and prolapse of the uterus, and for inspecting the bladder and 
rectum after atmospheric distention. 

When the woman assumes the knee-chest position it is usually neces- 
sary, except in the case of multiparas, to retract the posterior vaginal wall. 
Unless the uterus and base of the broad ligaments are fixed by inflammation 



EXAMINATION OF THE PELVIS AND ABDOMEN 



117 






that the front of the chest lies in contact with the table. The thighs are 
flexed at right angles to the abdomen, and the legs at right angles to the 
thighs ; the right thigh is flexed more than the left, so that the right knee 
lies above the left. A small, firm pillow placed beneath the hips will, by 
securing greater inclination of the pelvis, increase the efficiency of the 
position. This position is especially desirable for making an inspection of 
the anterior vaginal wall. It may also be used in place of the knee-chest 
position for making cystoscopic or proctoscopic examinations. 

In treating a patient for retroversion or prolapse of the uterus it is often 
a good plan to have her acquire the habit of falling asleep in the Sims' posi- 
tion, reversing it at will, and lying alternately on the right and on the left side. 

Supine Position (Fig. 104). — This is the position of choice in perform- 
ing palpation of the abdominal viscera. The patient lies flat upon the back 
with some elevation of the shoulders and head. The thighs are 
slightly flexed upon the abdomen ; the knees are bent and supported by a 




Fig. 106. — Sims' speculum. 

pillow beneath them, or by resting the feet upon a chair placed at the 
end of the table. 

The erect position is employed in inspecting the contour of the abdom- 
inal wall in cases of fat and overhanging abdomen, relaxed and 
protuberant abdomen, visceroptosis, etc. The erect position is also valuable 
in determining faulty and improper habits of dress and of carriage which pro- 
duce abnormal postures. 

Preparation of the Hands. — The examining hand should be protected by 
a rubber glove. In making palpation of the rectum great care should be 
observed to prevent carrying infection from the vagina to the rectum. For 
this reason, in passing from one region to the other the glove should be 
changed or thoroughly washed and immersed in an antiseptic solution. 

Lubricant. — Some form of lubricant is usually required, but should 
never be used when smears are to be taken from the urethra, Bartholin's 
glands, or the cervix. Glycerin is a very good lubricant; petroleum 
jelly and oil are quite commonly used. The most satisfactory lubricant is a vege- 
table jelly made up of gum tragacanth, 6 drams (25 gm.) ; phenol, 



118 



GYNECOLOGY 



(2 gm.) ; glycerin, iy 2 ounces (50 c.c.), and water enough to make two pints 
(1000 c.c). The lubricant should either be poured upon the fingers or ex- 
pressed from a collapsible tube. 




Fig. 107. — -(A), Bivalve speculum. (B) , Trivalve speculum. (C), Collapsible tube of lubricant,_ (D), Ultzmann 
syringe with roughened and perforated tip which may be wrapped with cotton for intrauterine injections. 

Illumination. — In making an examination it is very essential to have a 
good light. The examining table should be placed preferably before a 
window, but if this is not at hand, a strong light that can be reflected at will 
should be provided. For this purpose a portable electric lamp or an electric 
lamp and a head-mirror may be employed. 



EXAMINATION OF THE PELVIS AND ABDOMEN 



119 




Instruments. — A number of specula are required; at least one Sims' (Fig. 
106), a bivalve and a trivalve speculum (Fig. 107), and a large-sized Kelly cysto- 
scope to be used as a vaginal speculum in virginal women (Fig. 108). 
The speculum should be well lubricated before it is introduced. It is 
generally well to determine the posi- 
tion of the cervix by simple digital 
examination previously, and then to 
introduce the instrument toward 
that point with its blades in the 
oblique axis of the vagina. 

The bivalve and the trivalve 
specula may be used with the pa- 
tient in the dorsal position, since 
they hold the vaginal walls well 
apart for inspection. By gently ro- 
tating the instrument the entire 
vaginal wall may be brought into 
view. 

The Sims' speculum is used with 
the knee-chest or the Sims' position, 
or with the dorsal position when as- 
sistants are at hand ; both the ante- 
rior and the posterior walls may be 
retracted by separate specula. 

Double Tenaculum. — A double 
tenaculum is often of great assist- 
ance in bringing the uterus within reach of the finger in the rectum, and for 
the purpose of assisting in making bimanual replacement of the uterus. 



J 



Fig. 108.- 



-Kelly's urethral specului 
ining virgins. 



useful in exam- 



SPECIAL METHODS OF EXAMINATION 

Exploration of the Uterus with a Sound. — The uterine sound (Fig. no) 
should not be inserted during an office examination unless the vagina has 




Fig. 109. — Double tenaculum 



been thoroughly disinfected. In rare instances it may be used for the 
purpose of determining the exact position and depth of the uterine cavity. 
Intrauterine Digital Palpation. — Digital palpation of the interior of the 
uterus is impracticable unless the organ is or has recently been pregnant. An 
exception to this rule may be found in the case of submucous myomata or 



120 



GYNECOLOGY 



cervical or endometrial polypi that are being extruded through a softened 
and dilated cervix. 

Dilatation of the cervix sufficient to permit the introduction of the finger 
ma}* be made with the graduated metal dilators of Hegar or the branched 



dilators of Goodell (Fig. 



in 



In most cases preparatory softening and dila- 




FlG. no. — Long thumb forceps, uterine sound, applicator, spatula, curved dressing forceps. 




Fig. in. — Goodell's dilator. 



tation are necessary and desirable. The introduction into the lower uterine 
segment, cervical canal, and vaginal vault of sterile gauze will usually 
effect sufficient softening and dilatation of the cervix within twenty-four 
hours to permit digital examination at once or after the use of moderate 
instrumental dilatation. If the size of the introitus will permit, the entire 
hand may be well lubricated and introduced into the vagina. Digital 



EXAMINATION OF THE PELVIS AND ABDOMEN 121 

exploration should always precede the use of the blunt curette or the pla- 
cental forceps, and repeated explorations with the finger should be made 
during the removal of placental tissue. The finger alone can determine 
accurately the site of the retained portions and ascertain whether the uterus 
has been completely evacuated 

Diagnostic Curettement and Test Excision. — Curettement of the uterus for 
diagnostic purposes is of value for two reasons : First, the curette will reveal 
any unevenness or distortion of the uterine cavity to the trained hand ; and 
secondly, the scrapings obtained may be subjected to microscopic examina- 
tion (Figs. 112 and 113). 

In obtaining scrapings for microscopic examination the surgeon should 
be certain that every portion of the uterine interior has been reached by 
the curette, and that all the scrapings have been sent to the pathologist. 
(See Technic of Curettage, Chapter XII.) The endometrial fragments or 
shreds should be received in sterile salt solution, in which the blood-clot 
should be separated from the curettings ; the latter should then be placed in 



Fig. 112. — Sims' curette. 



Fig. 113. — Martin's curette. 

a 4 per cent, solution of formalin or in Zenker's fluid to fix and harden. Sections 
for histologic examination should be made from every part of the curettings. 

The differentiation between benign and malignant affections of the 
endometrium and cervix is possible in many instances only as the result of 
histologic examination. At this point a word may be said upon the advis- 
ability of having the examination made by a pathologist who is thoroughlv 
familiar with the appearance of the tissues in benign and malignant affec- 
tions of the pelvic organs. A reliable general pathologist or microscopist 
may often be led into serious error or uncertainty because of an unfamiliarity 
with the benign changes in structure that the cervical or intrauterine 
mucosa may undergo. 

Test excision of a piece of the cervix (Fig. 114) as a means of making a 
diagnosis is of great value, particularly in confirming or disproving a 
suspicion of malignancy. The excision may be made under local anaes- 
thesia, but, as a rule, mild general narcosis is preferable. Careful asepsis 
must be observed. The excised portion must include the entire extent of 
the suspicious area; it should be immediately placed in 4 per cent, formalin 
solution or Zenker's fluid for hardening and fixing. Catgut sutures should be 
at hand to coapt the cut surfaces. 



122 



GYNECOLOGY 



The gross examination of scrapings from the uterine interior and the 
macroscopic inspection of cervical lesions will often yield reliable informa- 
tion as to the nature of the disorder. Thus to the trained eye the villous 
appearance of fresh placental tissue from early embryos, the smooth, velvety 
thickening of the mucosa that has been transformed into decidua, the tough, 




Fig. 114. — Excision of diseased cervical tissue for microscopic examination. 

lumpy pieces of retained placenta, the friable fragments of carcinomata or 
sarcomata, and the scanty, thin shreds of atrophic endometrium, are all 
more or less easily recognized and characteristic. Of course, no one will 
rely upon this test alone, and histologic examination should always be made 
to confirm or disprove the diagnosis. Malignant affections of the cervix 
may almost invariably be recognized as such if the patient is anaesthetized 
and the suspected area is curetted. In the case of carcinoma or sarcoma the 
tissue is friable and brittle and easily detached from the surrounding healthy 



EXAMINATION OF THE PELVIS AND ABDOMEN 



123 



tissue, leaving a depression that may be small in early cases and large in 
later ones. Here, too, the gross evidence must not be regarded as conclu- 
sive, and histologic specimens must be prepared. It is only by microscopic 
examination that the very early carcinomata of both the endometrium and 
the cervix can be detected. (See Carcinoma of the Uterus, Chapter XVIII.) 
Smear Preparations as an Aid to Diagnosis. — In making a diagnosis of 
gonorrhoea it will usually be necessary to examine smears from the urethra, the 
glands of Bartholin, or the cervix. When the making of these smears is 
anticipated, the patient should be directed to omit douching and to hold 
the urine for some time previous to the consultation. No lubricant should 
be used on the examining finger. 






' 



,1.1-' 



Fig. 115. — Inspection of the external genitalia 
and expression of discharge from urethra. 



Fig. 116. — Inspection of the external genitalia, and 
expression of discharge from Bartholin's glands. 



After exposing the vulva any secretion upon the external surface should 
be lightly wiped away with a pledget of cotton. The urethra, Skene's 
tubules, and Bartholin's gland on each side should then in turn be emptied 
(Figs. 115 and 116), and the discharge gathered up on a probe or a platinum 
loop and transferred to a glass- slide. 

After the external genitalia have been carefully cleansed and disin- 
fected, the cervix may be exposed by means of a bivalve or a trivalve 
speculum. The discharge covering the vaginal cervix and portio should be 
removed, and an applicator wound with cotton should be passed into the 
cervical canal, moved about in all directions, and then rubbed upon a 
glass slide. 

It is useless, as a rule, to search for the gonococcus in a discharge that is 
found in the vagina or upon the vulvar surface, since so many other bacteria 
are present, and this association with other organisms causes the gonococcus 
to lose its identity. An exception to this rule must be noted in infants 
affected with vulvar or vaginal gonorrhoea of the florid type. 



124 



GYNECOLOGY 




Ftg. 117.- 



-Gonococci stained in smear. 
(Wilson.) 



After the smears have been made they should be permitted to dry and 
should then be fixed by passing them through the flame of a Bunsen burner 
three times, each passage being sufficiently slow to allow the glass to heat 
to a degree that is just unbearable to the touch. The smeared surface may 
next be covered with a saturated watery solution of methylene-blue or gentian 
violet, and allowed to stand for two or three minutes. The smear is washed in 

water, permitted to dry, and then examined 
tinder an oil-immersion lens (Fig. 117). 

This plan usually suffices for recogni- 
tion of the gonococcus. The organisms 
have a characteristic shape and grouping, 
and are generally found in the pus or in 
the epithelial cells. If any doubt as to 
their identity exists, a smear may be 
stained by Gram's method, in which the 
gonococcus is decolorized and takes the 
counterstain. In a case of Neisserian in- 
fection as time goes on the gonococcus 
becomes modified in appearance, a fact 
that probably accounts for the rarity with 
which they are found in chronic as com- 
pared with acute cases. The only abso- 
lutely positive method of identifying the gonococcus under these circum- 
stances is by means of cultures. These should be made only by an experi- 
enced bacteriologist. The search for the gonococcus in smears from the 
cervix is most likely to prove successful if the smears are taken just before 
or just after the menstrual periods. Old urethral infections may be brought 
to light by alcoholic excesses, especially the drinking of beer. The examina- 
tion of smears should repeat- 



edly prove negative before the 
patient is dismissed from medi- 
cal attention. 

Demonstration of Trepon- 
ema (Spirochasta) Pallidum.— 
The organism of syphilis may 
be found in smears from pri- 
mary and secondary syphilitic 
sores. In suspected cases the test 
should be made from any suspi- 
cious ulcerated areas. A drop of the serum or exudate should be mixed with a 
drop of India ink. Microscopic examination can be made immediately with 
a high-power lens, or later with an oil-immersion lens, if the mixture is 
spread out in a thin film and allowed to dry (Fig. 118). The spirochaeta may be 
detected in the serous transudate obtained by lightly curetting the edge of 
the lesion if stained with India ink or Goldhorn's or Giemsa's stains. The 
organism may also be recognized in the fresh unstained secretion from 
primary lesions and mucous patches with the aid of microscope and dark- 
field illumination. 




Fig. 118. — Spirochasta pallida. Smear made from chancre 

stained by india-ink method. (Hiss and Zinsser's Text Book 

of Bacteriology, D. Appleton & Co.) 



EXAMINATION OF THE PELVIS AND ABDOMEN 



125 



Pelvic Examination. — Inspection of the external genitalia should be 
the first step in a pelvic examination. By it the existence of leucorrhoeal 
discharge and the presence of venereal sores or of any other lesions of the 
vulva may be detected. In- 



m 



^ 



spection will at once yield cer- 
t a i n valuable information. 
For example, a virginal in- 
troitus will exclude the dis- 
eases due to pregnancy and 
childbirth ; a reddening of the 
orifices of Skene's tubules and 
of the ducts of the vulvo- 
vaginal glands will suggest 
gonorrhoeal infection ; an im- 
perforate hymen will explain 
the absence of the menstrual 
flow ; extensive lacerations of 
the perineum, cystocele, rec- 
tocele, etc., are often revealed 
at a glance. 

The cervix and the vaginal 
fornices are next exposed by 
means of a speculum (Fig. 
119). The state of the vaginal 
mucosa, whether bathed in 
leucorrhoeal discharge or be- 
reft of its natural moisture, 
and the presence of erosions 
or of inflammation are at once 
apparent. The contour of the 
cervix, the amount and the 
character of the cervical dis- 
charge, and the presence of 
gross lesions may be detected. 
Aside from the question of 
cervical diseases, inspection of 
the cervix gives evidence of 
previous labor or abortion. 

Palpation. — Evidence o f 
the presence of a gonorrhoeal 
infection may be obtained by 
" milking " Skene's tubules 
and the vulvovaginal glands. 
The friability and induration of 
a carcinomatous growth, the 
peculiar disk-like hardness of a chancre, the fluctuation of a vulvovaginal cyst, or 
the tenderness and induration of an inflammatory affection may be noted. The 
condition of the perineal floor may be ascertained, the presence of cystocele and 




Fig 119. — Exposure of vagina and cervix by bivalve speculum. 



126 



GYNECOLOGY 



rectocele, and the spastic contraction encountered in cases of vaginismus 
may be detected. The friability of a cervical growth, softening or induration 
of the cervix, or an increase in the patency of the cervical canal — all may be 
quickly ascertained. 

Palpation of the vaginal vault yields additional information. In front of 
the cervix the sharp kink of an anteflexion may be recognized ; in well- 




Fig. 120. — Touch picture. Simple digital examina- Fig. 121. — Touch picture. Simple digital examination 

tion and schematic outline of anteflexion. The index and schematic outline of retroflexioversion. The cervix 

finger feels the small conical cervix directed forward: is directed forward: the body of the uterus can be felt 

the body of the uterus can be felt through the ante- through the posterior wall, 
rior vaginal wall. 

marked cases of retroposition the body of the uterus may be felt through the 
posterior vaginal fornix, and often also an angle of flexion between the 
cervix and the body. An ovary prolapsed into Douglas' pouch is 
easily detected. 

While this simple digital examination yields considerable information, 
no examination is complete without bimanual palpation. By this method 




Fig. 122. — Touch picture. Simple digital examina- 
tion and schematic outline of pelvic mass. The 
cervix is forward under the symphysis: back of it 
through the posterior vaginal wall a rounded pro- 
jecting enlargement filling the hollow of the sacrum 
can be made out. 



Fig. 123. — Touch picture. Schematic outline show- 
ing prolapsed ovary palpable on digital examination. 
A body about the size of an olive is felt through the 
posterior vaginal fornix, slightly to one side of the 
median line. 



the pelvic organs are picked up one after the other between the palpating 
hands, and their size, mobility, consistency, and sensitiveness are esti- 
mated. The feasibility of a satisfactory bimanual palpation in a given 
case will depend upon the degree of relaxation of the abdominal 
muscles which the patient is able to induce voluntarily, and upon the amount 
of adipose tissue present in the abdominal walls. Rigid or thick abdominal 
parietes render bimanual examination difficult or unsatisfactory unless an anaes- 
thetic is employed. 



EXAMINATION OF THE PELVIS AND ABDOMEN 



127 




In bimanual palpation (Figs. 120 to 127) the palmar surface of one hand 
is placed upon the abdominal wall, and one or two fingers of the other hand 
are introduced into the vagina or into the rectum (Fig. 128). Palpation is 
made first with the organs in the posi- 
tion in which they are found. Later, 
except in acute or subacute pelvic in- 
flammatory disease, if it is found desir- 
able, bimanual palpation may be made 
with a finger in the rectum while the 
uterus is drawn downward by means 
of a tenaculum. This maneuver 
brings the entire posterior surface of 
the uterus within reach of the examin- 
ing finger and permits a minute ex- 
amination of the posterior surface of the 
broad ligaments and of the pouch of 
Douglas to be made. 

In bimanual palpation the cervix is 
located with the vaginal finger and 

fVi^ rlir^ntinn nf flip pprviral avid in re- £ IG ' I p 2 4-— Bimanual examination and schematic out- 
tne direction OI tne Cervical aXIS m re llne of anteversion and pathologic anteflexion. (To 

lation to that of the vagina is noted. ^^S^^lSd St £& cStHS. 

Normally the cervix is at almost a right The ^^^^^y^^**^ th. 

angle and points toward the coccyx. 

If it is found in the axis of the vagina, it is quite likely that the uterus is 

retroverted or that the patient is suffering from an acute anteflexion of the 
The body of the uterus is the next to be examined. If it is in nor- 
mal position — anteversion and anteflexion 
— it may be palpated between the vaginal 
finger placed upon the anterior vaginal 
wall, just in front of the cervix, and the 
abdominal hand pressed downward and 
toward the pelvic outlet in the median 
line above the symphysis. If the fundus 
is not located by such a maneuver, there 
is evidence of malposition. The 
vaginal finger is now carried back of the 
cervix along the posterior vaginal vault, 
while the abdominal hand is passed down- 
ward below the sacral promontory. In 

Fig. 125.— (Study in connection with Fig. 121.) cases of well-marked retroversion the pos- 

S^Sex^fe^T^bo^^&uSlterior surface of the body of the uterus 

cannot be felt between the finger in contact with ' w [\l ^g f e l t inclining backward toward the 
the anterior vaginal wall and the suprapubic ° 

fingers. The body of the uterus is posterior and sacrum, and if retroflexion is present, the 

is felt between a finger on the posterior vaginal . 1111 

wail back of the cervix and the abdominal angle between the cervix and the body 

can readily be made out. In addition to 
the position, the size, consistency, mobility, shape, and sensitiveness of the 
uterus may be determined. 

In palpating the left adnexa (Fig. 129) the vaginal finger is carried to the 



cervix. 




128 



GYNECOLOGY 



extreme left lateral part of the vaginal fornix, and pressed upward along the 
pelvic wall as far as possible, while the abdominal hand is gently pressed 
downward and forward over the brim of the true pelvis to the left of the 
sacral promontory. The finger in the vagina and the fingers of the abdom- 




FiG. 126. — (Study in connection with Fig. 122.) 

Bimanual examination and schematic outline of 

pelvic mass. The uterus and the pelvic mass may 

be recognized as separate bodies. 



Fig. 127.— (Study in connection with Fig. 123). 

Simple digital examination and schematic outline 

of prolapsed ovary. 



ir 



\\sv\Vi \xv§ 



FlG. 128. — Position of hands in bimanual examination of the pelvis. The elbow supported by the hip 
indents the perineum and permits a free manipulation of the fingers of the palpating hand. 



mal hand are approximated at the highest lateral and posterior position 
possible and then drawn gently forward. By this means the normal ovary 
and tube are brought between the fingers. The normal ovary is felt as a 
smooth, elliptic body, about the size of an almond, which slips or slides 
from the touch and is freely movable. The normal tube is made out with 



EXAMINATION OF THE PELVIS AND ABDOMEN 



129 



difficulty, giving to the examining finger the impression of a very soft rubber 
tube about the caliber of a lead-pencil. It is only in exceptional cases 
that the examiner can be certain that the tube is felt. Muscular strands in 
the abdominal wall or the round ligament will often be mistaken for a normal 
tube. The right adnexa may be palpated by similar manceuvers on the 
opposite side. 

If the ovary is adherent, the organ will be felt to be immovable and 
somewhat enlarged, and as though it 
were attached to the pelvic wall or 
floor. If the tube and the ovary are 
enlarged and adherent, they form an 
irregular, retort-shaped mass in which 
it is difficult to distinguish one organ 
from the other. 

It must be remembered that the 
position of the uterus will influence the 
position of the ovary. Thus, if the 

UterUS is retroverted Or prolapsed, the Fig. 129.— Schematic outline showing the relative 

„ , . mi 1 „ 1 j „„ „„ *X,„ position of the vaginal and abdominal fingers in 

OVary Will be lOWer and nearer the y bimanual examination of the tube and ovary. 

median line; when the uterus is in the 

normal position, the ovary will be higher and more laterally situated. When 
the ovary is prolapsed (Fig. 127), it may be felt by turning the palmar surface 
of the finger backward and palpating Douglas' cul-de-sac by pushing back- 
ward and outward. The ovary will be recognized as a smooth, elliptic 





Fig. 130. — Bimanual examination with uterus drawn 

down and a finger in rectum. The entire posterior 

wall of the uterus is made accessible to the rectal 

finger in this way. 



Fig. 131. — Combined recto-vaginal examination. 
Index finger of lower hand in rectum, thumb in 
vagina. Other hand in usual position on abdomen. 
Method is useful in locating position of cervix in 
relation to intra-pelvic masses. 



body that slips away from the examining finger. A scybalous mass in the 
rectum gives to the finger a sensation much like that of a prolapsed ovary; 
but the latter may be excluded by noting that the former pits on pressure or as 
the result of an examination made per rectum. 

Bimanual rectal palpation (Figs. 130 and 131) with the uterus drawn 
downward by means of a tenaculum is a most valuable aid to diagnosis in 
affections of the tubes and ovaries. The finger is inserted into the rectum 
9 



130 



GYNECOLOGY 



and pushed backward and downward until it passes between the uterosacral 
ligaments ; it is then turned upward upon the posterior surface of the uterus, 
and to either side upon the posterior surface of the broad ligaments. In 
making a bimanual examination with a finger in the rectum, it is some- 
times advantageous to insert the thumb in the vagina in order accurately 
to ascertain the position of the cervix; by this means also the thickness of 
the rectovaginal septum may be estimated. The method is chiefly useful, 
however, for distinguishing between uterine and other pelvic enlargements. 
In the case of inflammatory affections of the ovaries and tubes, irregular 
masses will be felt back of the uterus on one or on both sides, displacing it 
forward. When an inflammatory affection involves the cellular tissue of the 




Fig. 132. — Trimanual examination, case of ovarian cyst. (Clark.) 



broad ligaments, a dense, board-like induration is felt at the vaginal vault 
extending all the way to the pelvic wall and fusing with it. 

Pelvic masses occurring without induration of the vaginal fornices or 
the bases of the broad ligaments are usually uterine or ovarian in origin — 
uterine, if they are in connection or move with the uterus ; ovarian, if they are 
distinctly separate from, and independently movable of, the uterus. Indura- 
tion of the broad ligaments or the vaginal fornices, with immobility or 
partial fixation of the uterus, is suggestive of inflammatory disease involv- 
ing the tubes and the pelvic peritoneum; it is indicative also of carcinoma with 
extension to the broad ligament or of cellulitis. Pelvic enlargements aris- 
ing slightly above the pelvic brim and decidedly lateral in position are, as a 
rule, inflammatory or malignant in type. Those that occupy a more or 
less median position and extend well into the abdominal cavity are usually 
new growths of the uterus or of the ovaries. 



EXAMINATION OF THE PELVIS AND ABDOMEN 131 

Trimanual examination (Fig. 132) is especially valuable for determin- 
ing whether a pelvic tumor is cystic or solid in nature. In conducting this 
examination the tumor mass is confined as closely as possible between the 
two examining hands, " while the percussion is made by an assistant. With 
light, quick taps, even small collections of fluid may be detected by the 
quick, responsive, pulsatile wave passing from the abdominal to the pelvic 
hand" (Clark). 

This method is valuable also in differentiating between semi-solid and 
cystic tumors ; as, for example, in differentiating between a soft intra- 
ligamentary myoma with associated inflammatory disease of the appendages 
and a pelvic abscess, or in distinguishing a dense hydrosalpinx or pyosalpinx 
from a solid tumor. 

Abdominal Examination. — The abdominal examination may precede or 
follow the pelvic examination. 




Fig. 133. — Lateral aspect of abdomen with large myomatous uterus. Note the slight irregularity of 
the surface, and the sharp suprapubic rise and epigastric fall. (University Hospital.) 

Inspection. — The abdomen should be inspected from the sides, from the 
foot, and from the head as the patient lies in the supine position, and from the 
side as she stands erect. Inspection at once discloses the color of the 
skin, the evidence of previous counter-irritation and the scar of former 
operations ; enlargement of the cutaneous veins significant of femoral, iliac, 
mediastinal or portal obstruction may also be observed. The linea albicantes, 
usually indicative of past or present pregnancy, may be seen. The uniform 
enlargement common in tympanites, large ascitic collections, and thin- 
walled cysts filling the entire abdomen is to be noted. The flattened sur- 
face and bulging flanks of the relaxed or the moderately ascitic abdomen, 
the scaphoid surface indicative of emaciation, the enormously thick pan- 
niculus adiposus of the abdominal wall, the pendulous abdomen when the 
patient is erect, are revealed at the first glance. If the abdomen is protuberant 



132 GYNECOLOGY 

or distended in such a way as to suggest an abdominal tumor, the examiner 
should note whether the entire abdomen or only a particular area is affected ; 
whether, in the case of a median enlargement affecting the lower part of 
the abdomen, both sides are equally involved ; whether the surface of the 
enlargement is regular or irregular ; whether the abdominal respiratory 
wave affects the entire abdominal wall uniformly (tympanites, fat) ; 
whether a localized enlargement moves with respiration (kidney, gall- 
bladder, and stomach tumors, unless adherent) or is fixed ; and whether the 
respiratory wave stops at a point where the abdominal wall is splinted by 
the underlying tumor (uterus and ovary). 



Fig. 134. — Anterior aspect of abdomen, with large myomatous uterus, deviated 

to right. Note the slight irregularity of the surface and the greater prominence 

on the right side. (University Hospital.) 

Palpation.— Palpation confirms some of the observations made by in- 
spection, as, for example, the degree of abdominal distention and the local- 
ization of regional enlargements ; it also elicits much additional information. 
It determines the respiratory mobility or immobility of the tumor, and dis- 
closes rigidity or flabbiness of the abdominal muscles, tenderness, and 
muscle spasm. Palpation reveals the nature of an abdominal enlargement, 
making it possible to differentiate between the soft panniculus of the exces- 
sively fat abdomen, the tense elastic resistance of a cyst, and the hard, un- 
yielding mass of a solid abdominal tumor. The thickness of the adipose 



EXAMINATION OF THE PELVIS AND ABDOMEN 



133 



layer of the abdominal wall may be judged by picking up the layer of fat 
between the two hands. 

Palpation determines more or less accurately the point of origin of an 
abdominal tumor, and supplies information as to the organ from which it 
springs. In the case of an abdominal tumor springing from the pelvic organs 
the fingers pressed into the abdominal wall above the symphysis meet with 
firm resistance. Similarly in most ab- 
dominal tumors, the greater part of the 
periphery is usually free and distinctly 
palpable, whereas as the point of origin 
of the growth is approached it fuses 
with the organ from which it sprang 
and may be more or less indefinite in 
outline {e.g., gall-bladder enlargements, 
splenic growths). The passive mobility 
of tumors varies. Intraperitoneal 
neoplasms, pedunculated uterine and 
ovarian tumors, and intestinal and 
mesenteric growths are usually freely mobile — i.e., they can be moved freely 
toward the umbilicus — but they generally show a tendency to return to the 
area from which they grew. Conversely, retroperitoneal growths and kid- 
ney, suprarenal glands, and pancreatic tumors are more or less fixed. The 
same is true of inflammatory tumors and of those that are adherent, as well 
as of malignant infiltrating growths (Figs. 133 to 139). 




Fig. 135. — Anterior aspect of abdomen, with 
extreme ascitic distention; same case as 
Fig. 136. Note uniform and symmetrical dis- 
tention. (Stetson Hospital.) 




Fig. 136. — Lateral aspect of abdomen, with extreme ascitic distention. Note the gradual 
suprapubic rise and epigastric fall. (Stetson Hospital.) 

The presence of fluctuation is elicited by palpation and percussion. By 
this means collections of fluid may be distinguished from gaseous or solid 
enlargements. Fluctuation may be simulated by fat, but the percussion 
wave in the latter may be checked by pressure of the ulnar surface of an 
assistant's hand between the palpating and percussing fingers. Thick, tensely- 
walled cysts may give indefinite fluctuation, and may be mistaken for elastic 
resilient solid tumors. In large ovarian cysts which contain one large 
and many small cavities fluctuation may be elicited over the main cavity, 



134 



GYNECOLOGY 



but not over the smaller ones. Fluctuation is sometimes best elicited by 
the trimanual method of percussion (vide supra). 

Before making palpation the hands should be well warmed. The palmar 
surface should be pressed gently against the abdominal wall, making deeper 




;,-.; ...US. ■■'■- 

4A 



FlG. 137. — Lateral aspect of the abdomen in a case of large ovarian cyst. (Philadelphia Hospital.) 




Fig. 138. — Lateral aspect of the abdomen in a case of pregnancy near term, primigravida. (Philadelphia 

Hospital.) 

pressure with the fingers as the patient's confidence is gained and the abdom- 
inal wall relaxes. 

Percussion. — All intraperitoneal abdominal tumors having their origin 
in the pelvis and of sufficient size to cause abdominal distention exhibit a 



EXAMINATION OF THE PELVIS AND ABDOMEN 135 

dull or a flat note over the summit of the growth. This is continued to- 
ward its point of origin — for example, in the case of pelvic tumors, as far as 
the symphysis — whereas the percussion-note becomes resonant or tym- 
panitic in the remaining peripheral areas (''coronal resonance"). These 
are dependent upon the approximation of the tumor with the abdominal 
parietes and the consequent displacement of the intestines. When an intra- 
peritoneal abdominal tumor is small and lies among the intestinal coils and 
not against the abdominal wall, the percussion-note over it may be un- 
changed or very slightly altered (Figs. 140 and 141). 

Retroperitoneal abdominal tumors, even when of large size, on percus- 
sion invariably exhibit resonance or tympany over the area of greatest con- 
vexity. In the case of extremely large growths, this resonant or tympanitic 




Fig. 139. — Lateral aspect of the abdomen in a case of ovarian cyst with extreme carcinoma- 
tosis of the abdominal cavity. (Philadelphia Hospital.) 

note may not be marked, but it is almost always recognizable on light 
percussion. The reason for this is obvious, since the growth, having its origin 
back of the peritoneal investments of the intestines, as it increases in size, 
necessarily pushes the intestines forward. 

Percussion is valuable also in detecting the presence of free fluid within 
the peritoneal cavity. Whenever an intraperitoneal collection of fluid comes 
in contact with the abdominal parietes, the percussion-note over the point 
of contact is dull. Thus, when a moderate ascites is present and the patient 
lies flat on the back, the fluid gravitates into the flanks, where it produces 
dulness upon percussion, whereas the intestines, floating upon the surface 
of the fluid and being, therefore, most prominent, give a resonant or tym- 
panitic note in the median line of the abdomen. If the patient is turned 
upon one side, the fluid gravitates to that side, increasing the area of dul- 



136 



GYNECOLOGY 



ness here, whereas the other side now clears up and the note becomes 
resonant or tympanitic. So, too, if the patient stands erect, the dulness is 
manifest over the lower part of the abdomen, directly across from one side 
to the other, and to a varying degree above the symphysis. It is only in 




r-Coron&l resonance 
of intestines 



Fig. 140. — Schematic cross section of the abdomen to show reason for coronal resonance in 

abdominal tumors. 




FlG. 141. — Schematic cross section of the abdomen to show reason for central 
resonance and lateral dulness in fluid collections, ascites. 



the case of intraperitoneal collections of fluid large enough to distend and 
fill the entire abdomen that the percussion-note is uniformly dull. When 
an intraperitoneal collection of fluid becomes encysted {e.g., in tuberculosis, 
peritonitis, carcinomatous ascites) there may be no alteration in the dulness 
produced by changes in posture. 



EXAMINATION OF THE PELVIS AND ABDOMEN 137 

Auscultation. — Auscultation determines the activity of the intestines by 
demonstrating frequency and character of the peristaltic sounds. The nor- 
mal fine gurgling sounds of the intestine may be contrasted with the exag- 
gerated, almost continuous peristaltic borborygmi in flatulent distention 
and early obstruction, or with the diminished, infrequent, or entire absence 
of peristaltic action in a dynamic ileus or peritonitis. 

Auscultation discloses the foetal heart-sounds in pregnancy after the 
fifth month, and the placental bruit in the later months of gestation. Excep- 
tionally a bruit may be heard over abdominal tumors that press upon the 
large blood-vessels at the brim of the pelvis. 

Mensuration of the abdomen is valuable chiefly for noting accurately the 
growth of abdominal tumors. Fixed points on the circumference around 
which the measuring tape may be applied should be selected. When the 
comparative measurements are made within a few days of each other, the 
lines of measurement should be indicated with an indelible pencil. One cir- 
cumference passes through the anterior and the posterior iliac spines ; an- 
other, through the umbilicus, and a fixed point on the spine at the position 
of the forward limit of the lumbar curve ; another circumference cuts the 
lower costal margin on each side and is perpendicular to the spine. Longi- 
tudinal measurements are also of use, notably that made from the ensiform 
process to the upper limits of an abdominal tumor, and from that point to 
the symphysis pubis. 

Remote Abdominal Organs. — A routine examination should be made of 
the gastric, gall-bladder, appendiceal, and renal areas, to determine the 
presence of enlargements, tenderness, or displacements. It is hardly neces- 
sary to point out that tumors of the stomach, gall-bladder, appendix, and 
kidney may occasionally resemble new growths of pelvic origin, or that 
symptoms arising from diseased conditions of these organs may closely 
simulate those of pelvic disorders. Moreover, if operative procedure on the 
pelvic organs is contemplated, it may be advisable to correct lesions in the 
abdominal viscera at the same time, and thus the plan and scope of the 
operation may be modified. 

BIBLIOGRAPHY 

Anspach, Brooke M. : Martin's Surgical Diagnosis. Lea and Febiger, Phila., 1909. 
Kelly, H. A. : Operative Gynecology. Appleton, New York, 18Q9. 

Winter, G., and Ruge, C. : Gynecologic Diagnosis, Edited by J. G. Clark. Lippincott, 
Phila., 1909. 



CHAPTER IX 
EXAMINATION OF THE URINARY ORGANS 

Urinalysis. — The urinary output is an index of the condition of the secre- 
tory and excretory urinary organs. The chemical methods of examination 
do not differentiate between lesions of the kidney, ureter, and bladder, but 
when examined microscopically, some points of difference may be found. 
(See Urinalysis, Chapter VII, page 108.) 

PALPATION 

Urethra. — The urethra is palpable throughout its entire length, the pal- 
pation being made per vaginam. The finger is lubricated and applied to 
the anterior vaginal wall. The internal urinary meatus is situated about half- 
way between the vaginal introitus and the cervix. The contents of the urethral 
canal may be expressed by " milking " the urethra. Undue sensitiveness 
may be indicative of urethritis, and suburethral abscess or cyst may be 
detected by this method. Palpation should be combined with inspection. 
(See pages 123 and 140.) 

Bladder. — The bladder may be palpated during the course of the ordinary 
bimanual pelvic examination, and in this way a tumor or a calculus of large 
size may be discovered. Small calculi easily elude palpation, and for their 
detection a more effectual method of examination {e.g., cystoscopy) is neces- 
sary. A diagnosis of stone in the bladder may also be made by the use of a 
vesical sound. The bladder is distended with water and an ordinary 
searcher is introduced ; a finger in the vagina may serve as a point 
of resistance. 

Ureter. — Palpation of the ureter is performed through the vagina or the 
rectum. The position of the hands is similar to that employed in bimanual 
pelvic palpation. The vaginal finger is passed to the cervix and then to the 
right or the left side, upon the surface of the vaginal fornix. The abdom- 
inal hand is meanwhile pressed downward, as in palpation of the adnexa, and 
when the tissues of the broad ligament are thus fixed, the fingers of the two 
hands are approximated and brought forward in an attempt to roll the 
ureter between them. If the ureter is enlarged it may be felt just in front 
and to one side of the vaginal cervix ; it feels like a thick cord, of about the 
caliber of a pencil, and may be extremely tender to the touch. In making 
bimanual rectal palpation the procedure is similar to that just outlined; the 
cervix is readily located through the rectovaginal septum. 

Kidney. — In palpating the kidney the patient is placed upon her back, 
the shoulders being slightly raised, and the knees and thighs flexed and 
resting upon pillows. One hand of the examiner is placed posteriorly in the 
angle between the lower border of the ribs and the spine ; the other hand is 
placed anteriorly below the border of the ribs in a corresponding position. 
The patient is now directed to take deep breaths and then to allow the air 
to escape from the lungs by rapid expiration with full relaxation of the 
1S8 



EXAMINATION OF THE URINARY ORGANS 



139 



abdominal wall. At the very beginning of this expiratory act the tips of 
the examiner's fingers are pressed deeply into the abdomen beneath the border 
of the ribs, and then gradually downward, in an endeavor to get the kidney 
between the two hands. If the kidney occupies its normal position, the 
lower pole may be felt; but occasionally, especially in fat subjects, it is not 
palpable. In the moderately movable kidney of normal size the lower pole 
only may be palpable below the costal margin at the beginning of expira- 
tion. If the kidney is unduly mobile, the deep inspiration forces the organ 
downward and the examiner's fingers pressed into the abdomen below the 
ribs push it below the costal margin. Anterior and posterior pressure can 
then be maintained by the thumb and fingers of the posterior hand, the 




Fig. 142. — Trimanual method of percussion of kidney. (Clark.) 



anterior hand then being free directly to palpate the anterior surface of the 
displaced kidney. In this way the size, regularity of surface, consistency, 
etc., of the kidney may be ascertained. A movable kidney that is otherwise 
healthy is not, as a rule, tender, except during or immediately after a 
Dietl's crisis. At this time, however, the kidney is extremely sensitive, and the 
abdominal wall covering it may be very rigid and spastic ; this is true also of 
cases of pyelitis complicating pregnancy or of any acute surgical condition 
of the kidney. 

In chronic surgical affections of the kidney, as, for example, tumor, large 
hydronephrosis, etc., the enlargement of the organ is evident, and simple 
palpation of the suspected region will readily reveal the condition. In renal 
calculus the kidney may not be palpable, but on making pressure over the 
kidney area, especially in the costovertebral angle, tenderness will prob- 
ably be noted. 



140 



GYNECOLOGY 



Early tuberculosis of the kidney may be present without any apparent 
enlargement of the organ, although, as a rule, tenderness on deep pressure is 
noted. In many instances of inflammatory lesions of the kidney a certain 
degree of lumbar rigidity will be observed. In pronounced enlargement of 
the kidney, the mass is readily made out, occupying a position between the 
ribs and the anterior superior spines anteriorly, and filling up the loin pos- 
teriorly. If a fluid accumulation is present, fluctuation may readily be dis- 
tinguished, and for this purpose trimanual palpation will be found of 
particular advantage (Fig. 142). 

PERCUSSION 

Percussion as an aid to 
diagnosis of kidney condi- 
tions is of no value except 
in massive enlargement of 
the organ. It is not used in 
making the diagnosis of 
movable kidney, and has distinctly less value than palpation 
in determining the size and position of an enlarged kidney. 
It has great value, however, in diagnosing an abdominal tumor 
springing from the kidney. Such tumors may bear a resem- 
blance to gall-bladder or pelvic enlargements. 

As renal tumors are retroperitoneal, tympany over the ab- 
dominal surface of the enlargement, especially upon the mesial 
aspect, is a constant finding ; an intraperitoneal enlargement, 
on the other hand, shows dulness over the most prominent 
area, with a surrounding tympanitic zone. In order to differ- 
entiate between the two forms of growth light percussion may 
be necessary. 

Murphy's Kidney Punch. — This diagnostic aid is carried 
out as follows : The patient, from whom all the clothing above 
the waist has been removed, is seated upright on a stool and 
bends as far forward as possible. The examiner's left hand is 
then placed flat over the kidney of either side, and pressed 
scope, with electric fi rm i y against the body. With the clenched right fist a sharp 
blow is then struck on the dorsum of the left hand. If acute 
congestion, infarction, retention of fluid in the kidney pelvis, or ureteral 
obstruction exists, the patient will cry out with pain. As a rule, no expres- 
sion of pain is elicited by striking over a healthy organ. 



Pig. 143. — Kelly's 
improved cysto 



INSPECTION 

Urethra — Urethroscopy. — The external urinary meatus is exposed by 
separating the smaller labia. In the normal nulliparous woman the meatus 
is a small slit, often hard to detect in the surrounding mucosa of the vestibule. 
In the woman who has borne children the orifice may stand open, and may 
exhibit a tendency to gape and expose the mucosa of the urethra and the 
openings of Skene's tubules. Prolapse of the urethral mucosa and urethral 
caruncle may readily be observed. 

In acute urethritis the mucosa of the urethral orifice is seen to be swollen 



EXAMINATION OF THE URINARY ORGANS 



141 



and red. In chronic urethritis, which is almost invariably due to gonor- 
rhoea! infection, Skene's tubules are prominent, and their orifices may be 
elevated and reddened (gonorrhoeal macule) ; they often contain pus, which 
may be expressed by making slight pressure from below. The mucosa just 
inside the urethral orifice may be inspected by separating the lips of the 
urethra with a delicate wire speculum. For inspecting the deeper urethra a 
cylindric speculum with an obturator is required. The end of the instru- 



1PQ 







Fig. 144. — Nitze catheterizing cystoscope, single. 



ment should be fitted with a small incandescent lamp, although light may 
be reflected through the barrel of the instrument by means of a head-mirror. 
In performing urethroscopy the bladder is emptied. The speculum is 
well lubricated and passed through the vesical neck into the bladder, and 
the obturator then removed. The instrument is now slowly withdrawn 
until the folds of the vesical sphincter begin to close over the end of the 
speculum. As the instrument is withdrawn the mucosa of the entire canal may 




Nitze examining cystoscope. 



t>e inspected from within outward. Fissure of the neck of the bladder, 
patches of chronic urethritis, the opening of a suburethral abscess, and the 
presence of infected follicles on the floor of the urethra may be discovered in 
this way. In order to correctly interpret the findings a certain amount of 
experience is necessary. The urethroscope should be short and the interior 
of the barrel darkened. A very fine, flexible, solid silver probe will be useful in 
locating infected follicles or in finding the opening of a suburethral abscess. 



__ 



142 



GYNECOLOGY 



Bladder and Ureteral Orifices — Cystoscopy. — Cystoscopy is probably the 
most valuable and certainly the most useful method of examination at our 
command in surgical conditions of the bladder, ureter, and kidney. Cystos- 
copy, as the name implies, is direct inspection of the interior of the blad- 
der. By its means the mucosa and the ure- 
teral orifices are directly exposed to view. 
In addition to morbid anatomic changes in 
both, the physiologic actions of the ureters 
can thus be studied. Since the activity of 
the ureters is dependent more or less directly 
upon the kidneys themselves, cystoscopic 
inspection yields considerable information 
concerning these organs. This is particu- 
larly true of chromo-uretero-cystoscopy. 
Furthermore, by sounding or catheterizing 
the ureters and by applying the methods 
that will subsequently be detailed, the con- 
dition of each kidney may be most accurately 
determined. 

Methods of Cystoscopy. — S e v e r a 1 
methods of performing cystoscopy are in 
vogue at the present time, each of which has 
its advantages and disadvantages. A very 
efficient but somewhat difficult method is 
that suggested and elaborated by Kelly. It 
consists of introducing a cylindric speculum 
(Fig. 143) into the bladder, with the patient 
in the knee-chest, Sims', or elevated dorsal 
position, so that the bladder becomes dis- 
tended by atmospheric pressure and its in- 
terior is exposed for inspection directly 
through the barrel of the instrument. The 
disadvantages of this method are that the 
patient is placed in a somewhat uncomfort- 
able position, that dexterity and prolonged 
practice are required to secure good results, 
and that since a speculum of considerable 
size is necessary in order to obtain a good 
view, the examination is somewhat painful. 
It has the advantages of requiring no com- 
plicated apparatus and of giving a direct view. 
Furthermore, local applications may be made or 
even simple intravesical operations performed 
through the open barrel of the speculum. 
Another method of performing cystoscopy is to distend the bladder 
with fluid and introduce a cystoscope that carries a light for illumination at 
its extremity and that possesses a series of mirrors and lenses through which 
the bladder may be viewed (Fig. 144) . There is usually some magnification of 




Fig. 146. — Cylindrical jar for sterilization 
of cystoscopes. 



EXAMINATION OF THE URINARY ORGANS 



143 



the bladder mucosa. The method possesses the following advantages : For 
simple inspection an instrument only slightly larger than the ordinary cathe- 
ter is required (Fig. 145) ; it causes but little pain and no discomfort, since the 
patient may lie in the ordinary dorsal position ; less practice is required to 
perform the cystoscopy satisfactorily ; the urethral orifices may be located 
with comparative ease, and ureteral catheterization may be practised with- 
out much difficulty. Its disadvantages are that a complicated and expen- 
sive instrument is required, while intravesical operations or applications, 
although possible, become more difficult and make an especially designed 
instrument necessary. 

General Preliminaries. — All cystoscopic examinations should be con- 
ducted under aseptic precautions. The external genitalia should be washed 
with green soap, water, and bichloride solution (1:1000). For simple 
cystoscopic examinations the vulva need not be draped with sterile cover- 
ing, but if the ureters are to be 
catheterized, this forms a very 
important part of the technic. 

The Kelly cystoscopes may 
be sterilized by boiling. Cys- 
toscopes fitted with lenses 
should be sterilized by im- 
m e r s i n g them for thirty 
minutes before using in a 
1 : 500 solution of formalin. 
Simple examining cystoscopes 
should be placed vertically in 
a narrow cylinder jar (Fig. 
146), the eye lens-system not 
being immersed. Catheteriz- 
ing cystoscopes must be en- 
tirely immersed. • They are 
either provided with a cap 
that protects the eye 

lens-system during the immersion, or they are so constructed that the lens- 
system may be completely separated from the instrument and sterilized by 
the method used for the simple examining cystoscopes. 

Ureteral catheters (Fig. 147) should, after use, be thoroughly but gently 
washed with castile soap and cold water. The lumen should be repeatedly flushed 
with water. This is best done in the following way : The catheters are 
suspended over the edge of a pitcher filled with cold sterile water, the eyes 
of the instruments being near the bottom of the pitcher and the butts hang- 
ing outside, reaching a lower level, so that siphonage may take place. 
The result is a continuous washing of the lumina for two or three 
hours, according to the amount of water used. The catheters should now be 
flushed with a 1 : 500 formalin solution, hung up, and allowed to dry. They 
should then be placed in the formalin gas sterilizer (Fig. 148). 1 




Fic. 147. — Ureteral catheter. 



1 Catheters which are to be used with the Kelly cystoscope must be kept straight and 
rigid; this is best accomplished by introducing a wire stylet into their lumen. This facili- 
tates the introduction of the catheter through the open barrel of the cystoscope. 



144 



GYNECOLOGY 



If it is found necessary to use a catheter that has become infected within 
twenty-four hours, the instrument should be flushed and then immersed in a 
cold i : ioo solution of formalin for at least thirty minutes. Hot water and 
alcoholic solutions affect the varnish of a catheter and quickly ruin it. 

Technic of the Direct Method with Atmospheric Distention of the 
Bladder — Kelly's Method. — A small pledget of cotton soaked in 10 per cent, 
cocaine is introduced into the urethra. After a few minutes the pledget is 
removed and the patient is directed to empty the bladder. She is then 
placed in the knee-chest or in the Sims' position, and the external urethral 
orifice is dilated up to 10 mm. The dilator (Fig. 149) should be well lubri- 
cated and a gentle boring motion should be employed. The speculum is 
gently introduced into the bladder, making sure that the instrument is well 



k 





Fig. 148.— Sterilizing ureteral catheters; jar with, 
ground glass lid; formalin pastilles and vapor. 



Fig. 149. — Urethral 
calibrator. 



within the internal urethral orifice when the obturator is withdrawn. Upon 
its withdrawal the air rushes through the speculum and distends the 
vesical cavity. 

It is customary to inspect first that part of the bladder directly opposite 
the end of the speculum, and which corresponds usually to the vertex of the 
bladder ; then, by sweeping the end of the instrument in various directions, 
to go over the entire mucosa, finishing with that part at the base of the 
bladder, just within the internal urethral orifice, known as the trigone. 

The trigone is the triangular area between the internal urethral orifice 
and the two ureteral openings. It is bounded posteriorly by a fold known 
as the interureteric ridge. In order to locate these anatomic points it is 
advisable, after completing the general inspection of the bladder, to with- 
draw the speculum until the internal urethral orifice begins to fold over its 
extremity. The speculum is then pushed into the bladder for a distance of 



EXAMINATION OF THE URINARY ORGANS 



145 




3 cm., and the inner end is tipped toward the base of the organ, when, as a rule, 
the instrument will be in close proximity to the interureteric ridge. The 
ureteral orifices are situated at the right and left extremity of this ridge, 
equally distant from the midline. They may be located by directing the 
speculum to the right or the left in the arc of an angle of between fifteen 
and thirty degrees from the midline. 

Hunner believes it a good plan to locate the left orifice first, as it is usu- 
ally situated nearer the internal urethral orifice than the right, and is more 
easily found than the latter because of the depression of the left vesico- 
vaginal wall produced by the weight of the 
uterus and the cervix. The right orifice is farther 
up toward the sacrum. 

The opening of the ureter is situated nor- 
mally on a localized elevation of the mucosa 
termed the mons ureteris. As a rule, it is most 
prominent on the left side, and is especially w r ell 
developed in women who have borne children. 
The appearance of the ureteral orifice varies 
considerably in different persons. In some it 
may be almost imperceptible, resembling a fine 
watermark in a sheet of paper, whereas in others 
it may be contracted and obscured by inflamma- 
tory sw r ellings that make its detection almost 
impossible. A guide to the ureteral orifice is 
often furnished by the periodic ejection of urine. 

Technic of the Indirect Method with Disten- 
tion of the Bladder by Water. — In this method 
the patient is placed in the ordinary dorsal posi- 
tion, and the bladder is carefully irrigated with 
warm saline solution, the irrigation (Figs. 150, 151 
and 152) being continued until the water returns 
perfectly clear. The bladder is now filled with 
sterile water, the patient being encouraged to 
retain as much as possible. With the bladder 
full the cystoscope is introduced. The electric 
lamp and lenses are so arranged that a large part 

of the bladder can be seen with equal clearness. The vertex of the bladder, 
including the area back of the symphysis, is first examined, then the sides 
are inspected, and finally the base of the bladder and the trigone are viewed. 
This inspection is accomplished by alternately advancing and withdrawing 
the instrument with the lens turned in various directions from the 
median line. 

The cystoscopist should be familiar with the appearance presented by 
the normal bladder. Unless the distention is marked, the bladder is not 
spheric in outline, but is somewhat flattened on its superior surface by the 
10 




Fig. 150. — Irrigating apparatus. 



146 GYNECOLOGY 

fundus of the uterus and pouched on either side. At the junction of the 
superior movable portion of the bladder with the base or fixed portion 
shadows may be seen ; these can be eliminated only by pressing the end of 
the instrument close to the bladder wall in the darkened area. 

Looking toward the apex of the bladder, an air-bubble is almost invari- 
ably seen on the surface of the distending medium. The mucosa of the 
apex may now be studied. As a rule, it presents a clear, pinkish-white sur- 
face, in which the capillaries are distinctly traceable, sharply defined in out- 
line, and of a bright red color. 

As the lateral areas are approached the lateral folds, appearing more or 
less as shadows, are observed. Here and there the surface of the mucosa 
may be marked by an underlying ridge of connective tissue. The color of the 
mucosa takes on a deeper hue, and the blood-vessels are increased in num- 
ber and more richly supplied with branches. At the base, in the midline, 
the color of the mucosa is a dull red, and the surface is no longer smooth 
and shining, but is thrown into fine ridges running toward the internal 
ureteral orifice. 

By pushing the instrument back in the median line as far as it will go 
and elevating the beak, the uterovesical fold may be brought into view, 
with the depression caused by the uterus immediately beyond it. Just in 
front of this area is the trigone, a triangular area bounded by imaginary 
lines connecting the ureteral orifices and the internal urinary meatus. The 
instrument is now drawn forward toward the internal urinary meatus until 
the posterior margin of the latter begins to rise in the picture ; the beak is 
then pushed inward about 3 cm., and directed first on one side and then on the 
other to a point about 1^2 cm. from the median line ; in this area the ureteral 
orifice can usually be located. 

The ureters appear as fine openings or slits in the mucosa, generally 
situated upon a rounded eminence. Between the two ureteral orifices a 
ridge of the mucosa can be seen ; this is termed the interureteric ridge, and 
forms the base of the trigone, containing muscle-fibers that are continuous 
with those of the ureters. The vessels of the trigone radiate toward the 
ureteral orifices on either side. About the ureteral orifices may be noted the 
anastomosis between the ureteral and vesical capillaries. 

Upon close observation of the ureters, periodically — the frequency 
depending upon the activity of the kidneys — the eminence will be seen to 
pout, bringing into relief the position of the ureter embedded in the bladder 
wall; it then retracts, the orifice opens, and there is an outward 
gush of urine. The orifice immediately closes and again becomes immobile. 
The ureters on the two sides act independently of each other in this periodic 
ejection of urine. 

Departures from the normal may be noted in the capacity of the bladder ; 
in the color and transparency of the mucous membrane ; in the number, size, 
and outlines of the capillaries; in the shape of the interior of the bladder; in 
the ridges caused by the submucous connective tissue ; in the position of the 
ureteral orifices, and in the appearance of the orifices themselves. 

Capacity of the Bladder. — The average female bladder will hold from 
250 to 300 c.c. of solution without causing marked discomfort to the patient. In 



EXAMINATION OF THE URINARY ORGANS 147 

fixed tumors and enlargements of the uterus or adjacent parts the capacity 
of the bladder may be diminished because of the inability of the vesical 
walls to distend. In old cases of cystitis, particularly in those of tuberculous 
origin, the capacity is greatly diminished, due to actual contraction and 
shrinkage of the submucous connective and muscular constituents of the 
bladder wall. 

Color and Transparency of the Mucosa. — In hyperemia and acute cystitis 
the mucosa is of a deeper pink or red color, and the translucency is dim- 
inished. In chronic cystitis the mucosa is a deeper pink or grayish in color, 
lusterless, or presents a ground-glass appearance. The folds about the 
trigone may be greatly enlarged, swollen, and ©edematous. Deposits of 
phosphates and pus may be observed as whitish particles that are adherent 
to the mucosa, or detached and floating in the distending fluid. Ulcera- 
tions appear as irregular, punched-out areas covered with whitish in- 
crustations of pus or deposits of urinary salts. 

Number, Size, and Outline of the Vessels. — The number of capillaries is 
increased in hyperemia ; if the condition goes on to actual inflammation, the 
outlines become less distinct. The medium-sized and smaller vessels become 
larger, but less distinct and even partly obscured by the fogginess of the 
mucosa. Small, red, sharply-defined points representing ecchymoses may 
be discerned here and there, and the slightest touch with the cystoscope 
may cause bleeding. 

Shape of the Interior of the Bladder. — The interior of the bladder may 
undergo changes in shape as the result of enlargements or tumors of the 
uterus or adnexa, which displace or encroach upon it. In cases of chronic 
cystitis the contractions of the bladder wall may be irregular, deepening the 
shadows on one side, drawing the trigonal area more to one side, and form- 
ing asymmetric ridges and hollows. 

Submucous Trabecular. — In chronic cystitis, particularly in those cases 
associated with obstruction to the urinary flow, the surface of the bladder is 
marked with numerous trabecular that cross one another in various directions, 
thus forming depressions, pockets, or diverticula of the mucous surface 
between them. 

Position of the Ureteral Orifices. — Subvesical tumors may displace both 
orifices to one side of the median line, or produce such an irregularity in the 
contour of the trigone that the orifices will be completely hidden from view 
in the shadows or folds. In chronic cystitis with ulceration and contrac- 
tion the orifices may be drawn far from their normal position and be hidden 
from view in the folds of swollen or ulcerated mucosa. 

The ureteral orifices may be swollen and oedematous, wide open, and 
rigid, showing little or no tendency to periodic relaxation or contraction, and 
slight or no swelling or retraction of the intramural part. Or the orifices 
may be " dead," entirely inactive, and evincing no contractions and no ejec- 
tions. They may be plugged with pus or excavated as the result of ulceration. 
One orifice may eject twice as often as its fellow. 

Catheterization of the Ureters. — After inspection of the bladder, if it is 
found desirable to catheterize the ureters, the simple examining instrument 
is withdrawn and the catheterizing cystoscope is introduced in its stead. A 



148 GYNECOLOGY 

rigid aseptic technic must now be observed. Theoretically, the direct 
method of cystoscopy is not so safe as the indirect method, for in the latter the 
catheters (Fig. 153) pass through a sterile medium (water) or a weak 
antiseptic solution (1 : 5000 mercury oxycyanide). If the bladder is sterile or 
has been thoroughly irrigated there is no great danger in either case. Never- 
theless, catheterization of the ureters should not be practised when the 
bladder is infected unless no other method of diagnosis will suffice. For 
the purpose of collecting the urine from each kidney separately the ureteral 
catheter need be inserted a distance of only a few centimeters. 

Catheterization of the Ureters by the Direct Method. — After having 
located the ureteral orifice, a sterile glove is slipped on the examiner's right 
hand by an assistant, who supports the tail of the catheter while the ex- 
aminer guides the tip through the lumen of the cystoscope into the ureteral 
orifice. After the tip is engaged in the ureter and as it is introduced fur- 
ther into the canal the stylet is withdrawn. A catheter of large size is 




Figs. 151-152. — Top and bottom view. Two-way irrigator or catheter. 

more practicable used with the Kelly open cystoscope than with the Nitze 
or any other form of catheterizing cystoscope. 

Through the open Kelly cystoscope may also be introduced ureteral cathe- 
ters or bougies that have been tipped with wax ; these will show the scratch- 
marks of ureteral calculi and are valuable as a means of diagnosis. 

A diagnosis of stricture of the ureter is more easily made by the direct 
than by the indirect passage of bougies, as the sense of resistance is more 
readily perceived. Ureteral sounds of increasing size may be used for the 
purpose of dilating strictures of the ureter in its lower part. 

Catheterization of the Ureters by the Indirect Method. — When the Nitze 
instrument is to be used, the examiner disinfects his hands and wears a 
gown and sterile rubber gloves. The cystoscope is rinsed in sterile water 
and dried. The ureteral catheter or catheters are threaded into the channels 
provided for them, the attachment for the electric current is protected by a 
sterile cover, and the cystoscope is introduced. 

The ureteral orifice on the side to be examined is exposed and the cysto- 
scope is maintained in that position. The ureteral catheter is now pushed 
through the barrel of the instrument until the point appears in the field of 



EXAMINATION OF THE URINARY ORGANS 



149 



vision. By means of the device provided in the instrument the tip of the 
catheter is directed toward the orifice and is made to engage. Still holding 
the cystoscope in the same position, the catheter is pushed onward as far as 
required (Fig. 153). The catheters used with this form of cystoscope are 
marked at one-centimeter intervals, so that the cystoscopist may know 
just how far the catheter has been inserted into the ureter. Where both 
ureters are to be catheterized it may be advantageous to use differently 
marked catheters on the two sides, so that the right does not become con- 
fused with the left. ^ 

If urine is to be collected from the catheterized ureter, the device used to 
direct the catheter may be turned back to the resting position ; the water in 




Fig. 



:S3. — Catheterization of the ureter. The cystoscope has been rotated to illuminate the trigone, and 
the shutter opened to assist in directing the catheter into the ureteral orifice. 



the bladder is then let out and the instrument is gently withdrawn, the 
ureteral catheter at the same time being pushed through the cystoscope 
until the tip of the latter emerges ; the catheter is then caught with the 
fingers and fixed as the cystoscope is detached from it. 

By this method obstruction of the ureter can be detected and treated. 
Catheters of varying sizes may be introduced in an effort to get past an 
obstruction or for the purpose of dilating a stricture of the ureteral orifice 
or lower ureter ; but the maneuvers are not so satisfactory as with the 
direct method of cystoscopy. 

In order to collect urine from one side, the catheter need not be passed 
for more than 5 or 6 cm. ; it is unnecessary to pass the instrument further 
than this, for traumatism of the ureter should be kept at a minimum, lest 



150 GYNECOLOGY 

blood or leucocytes become mixed with the urine and impair the value of 
the microscopic urinalysis. 

The end of the ureteral catheter should now be placed in a sterile test- 
tube plugged with sterile cotton ; the tube should be properly supported, and 
the patient placed in a comfortable position. When a sufficient quantity for 
urinalysis has been collected, the catheter may be withdrawn. 

Although it may be necessary, for diagnostic purposes, to pass the 
ureteral catheter into the kidney pelvis, it should be borne in mind that if 
the catheter is introduced so far that it doubles up in the kidney pelvis or 
encroaches upon the calices or pelvic walls, bleeding will almost certainly 
follow, and the value of the collected specimen, so far as the blood content 
is concerned, will be rendered void. 

Under normal conditions the urine drops from the end of the catheter at 
intervals of from ten to fifteen seconds ; two, three, or four drops follow in 
succession, then a pause occurs, and the dropping is repeated. If the drop- 
ping is continuous, it is an indication that the catheter has either entered a 
collection of fluid in the kidney, pelvis, or ureter (hydronephrosis, hydro- 
ureter) or that it has been drawn down into the bladder or that the rate of 
excretion is extraordinarily rapid as after the ingestion of a large amount 
of water. 

At first there may be no escape of fluid from the ureteral catheter. (Care 
should always be exercised beforehand to see that the lumen of the catheter 
is unobstructed.) If the catheter has been previously tested, it may be that 
the eye of the instrument has become plugged with pus or blood. Under- 
these conditions a few centimeters of sterile water may be injected through 
the catheter in order to dislodge the obstruction. A reflex anuria is some- 
times observed. This rarely lasts for more than a few minutes — at most, 
five or ten. 

Examination of the Ureter and Kidney by Means of a Wax-tipped 
Bougie. — The passage of a wax-tipped bougie through the ureter into the 
kidney pelvis is a valuable diagnostic means in cases of ureteral or renal 
calculus. Kelly uses a renal bougie 2 mm. in diameter, with an olive point 3 by 
2 mm., notched on two sides, the notch running lengthwise. Two parts of 
dental wax and one part of olive oil are melted together and the end of the 
catheter is dipped in the hot mixture and allowed to harden in the air. The 
wax gives the catheter a highly-polished surface, which is exceedingly 
sensitive, and becomes abraded by the slightest contact with a hard, rough 
substance. In order to ascertan the exact position of the stone, whether it is 
located in the ureter or in the kidney, it may be advisable to coat the entire length 
of the bougie. A stone that is low in the ureter produces a long, con- 
tinuous scratch along the extent of the catheter. The chief source of error 
in interpreting the marks on the wax is that they are apt to be confused with the 
scratches occasioned by contact with the cystoscope. (See Chapter XXV for 
the method of using wax-tipped catheters with the water cystoscope.) 

Kelly reports eighteen cases of kidney stone in which a positive diag- 
nosis was made by means of the wax-tipped catheter, and in which a sub- 
sequent nephrolithotomy confirmed the diagnosis. In two cases in which 
stones were present the waxed catheter gave no evidence of their existence. 



EXAMINATION OF THE URINARY ORGANS 151 

Kelly states that the wax-tipped catheter may fail to locate a renal cal- 
culus if the pelvis of the kidney is greatly dilated and if the stone is small, 
if the calculi are lodged in cavities in the substance of the kidney, or if a 
large stone has fixed the pelvis of the kidney and the catheter pushes out 
the upper end of the ureter until it forms a small pocket. 



FIG. 154- — Rontgenogram of ureteral stone. 



In doubtful cases, when the suffering is protracted and tends to cripple 
the patient, an exploratory incision for confirming the diagnosis of renal 
calculus is justifiable. 

Rontgenographic Examination of the Kidney. — Rontgenographic exami- 
nation of the kidney is of value, especially in the diagnosis of renal calculus. 



152 



GYNECOLOGY 



According to Henry Fancoast, " the rontgenographic examination is the 
most uniformly accurate, and, therefore, the most valuable method at our 
command in the diagnosis of renal calculus, provided it is employed intelli- 




FlG. 155. — Shadows cast by vermiform concretion and by phlebolith; upper shadow upon 

the iliac crest is cast by a fecal concretion in appendix, small round shadow in pelvic area is a 

phlebolith. (After Fenwick, from Kelly and Burnham: "Diseases of Kidney, Ureter and 

Bladder," D. Appleton & Co.) 



gently. The rontgenographic findings cannot of themselves, however, be 
accepted as absolute in every case, because of the possible existence of 
certain sources of error, which, though comparatively rare, must not be 
overlooked. Therefore, this method of examination should always be used 



EXAMINATION OF THE URINARY ORGANS 



153 



in conjunction with the other clinical methods of diagnosis and the symp- 
toms which in the first place suggest the examination. The percentage of 
error in diagnosis of renal and ureteral stone is variously placed at from 
four to ten (Fig. 154). 

" The degree of error possible in any individual case may be more or 
less approximately determined by consideration of the following four defi- 
nite factors concerned in the accuracy of the results of the rontgenographic 
examination for renal calculus: (1) The making of the rontgenogram; (2) 
the interpretation of the rontgenogram; (3) anatomic difficulties; (4) other 
conditions or objects, normal or pathologic, which may be capable of simu- 
lating the rontgenographic appearance of calculus. 




Fig. 156. — Rontgenogram of suspected renal calculus with sound in ureter. The arrow points to 

a shadow which was shown to lie outside of the ureter by a shadowgraph bougie. The shadow 

proved to be a patch in an atheromatous artery. (After Fen wick.) From Eisendrath's " Surgical 

Diagnosis." (W. B. Saunders & Co.) 



" In connection with the first factor we may consider the skill and ex- 
perience of the rontgenologist, the efficiency of his apparatus, and the pre- 
liminary preparation of the patient. As a rule, no rontgenogram should be 
accepted as of value for the diagnosis of renal calculus unless the intestinal 
tract of the patient has previously been thoroughly emptied of fecal matter 
by mild but efficient purgation. The stomach also should be empty, espe- 
cially when the left kidney is suspected. The rontgenologist should be certain 
that there is no possibility of pills or foreign bodies of any kind being pres- 
ent in any part of the gastro-intestinal tract. 

" An accurate interpretation of the rontgenogram requires equally as 



154 



GYNECOLOGY 



much skill and experience as does the examination itself. The examination is 
essentially a consultation ; therefore the rontgenologist must possess a 
reasonable amount of knowledge of anatomy and surgery ; and, likewise, 
the surgeon should possess a corresponding degree of skill and experience 
in interpreting rontgenograms of this kind. 

" The anatomic difficulties likely to influence the accuracy of the ex- 
amination are an excessive amount of fat in the abdominal walls or omen- 
tum, thick muscular walls, tumors, and ascites. A reliable rontgenogram 
of the kidney area should show at least the shadows of the psoas and 




Fig. is?. — Rontgenogram showing stone in upper calyx of right kidney. Note 

outline of kidney and relation of stone to short twelfth rib. (Kellv and Burnham. 

" Diseases of Kidney, Ureter and Bladder." D. Appleton & Co.) 



quadratus muscles, and, to be accurate, the shadows of the kidneys in addi- 
tion. If the result of an examination is positive as to stone, it should be 
repeated before any operation is performed. Two negatives made at the 
same visit will not answer: the two examinations should be made on 
different days. 

" A rontgenogram is a shadow picture, and unfortunately there may be 
present somewhere between the Rontgen ray tube and the plate other objects, 
normal or abnormal, which are capable of making a shadow similar to that of a 
calculus. This must be classed as an unavoidable source of error, though 
the degree of error may be more or less modified by the skill and experi- 



EXAMINATION OF THE URINARY ORGANS 



155 



ence of the rontgenologist. The most frequent examples of objects in the 
abdominal cavity which may produce misleading shadows are calcified 
lymph-glands, gas and fecal matter remaining in the intestinal tract due 
to careless preparation, pills or tablets not broken up or dissolved, fecal 
concretions, especially in the appendix, and collections of pus in the kidneys 
(Figs. 155, 156, 157 and 158). A mole on the back may cast a shadow of suffi- 
cient density to simulate a calculus. In the pelvis one may be easily misled 
by the frequent occurrence of shadows due to phleboliths in the pelvic 
veins, intestinal contents and calcified lymph-glands." 

Kummell secured perfect Rontgen ray pictures of calculi in sixty-five out of 
eighty-four cases that came 



to operation. 



large number of other 




\ 
\ 



An equally 
kid- 
ney affections that simu- 
lated calculus were operated 
upon but failed to yield posi- 
t i v e Rontgen ray findings. 
To arrive at a positive diag- 
nosis, several skiagraphs 
must be made, and each 
plate must show the calcu- 
lus to be in the same posi- 
tion. Kummell regards this 
constancy of position as 
most important in the dif- 
ferential diagnosis, and re- 
gards it as a characteristic 
sign of stone. As a rule, the 
calculus occupies a position 
on the Rontgen ray plate sev- 
eral centimeters from the 
spinal column and a little 
below the twelfth rib. cor- 
responding to the anatomic 
position of the pelvis of the 
kidney. This is about the 
point where an imaginary 
horizontal line drawn 
through the body of 

the second lumbar vertebra would meet the twelfth rib. When renal cal- 
culus complicates pyonephrosis, a greater variation in the position occurs, 
because such stones sink into the dilated and altered pelvis and grow like 
coral branches into the enlarged calyces. The resulting dentate mass pre- 
sents a more or less characteristic appearance that differentiates it from 
intestinal contents and from other foreign confusing elements. The diag- 
nosis of renal calculus by means of the Rontgen ray is made with difficulty in 
very stout subjects. This difficulty may be overcome partly by compressing the 
abdominal wall at the time the picture is taken. Pure phosphatic stones, 
being soft, very often give no shadow. 



V 



Fig. 158. — History in this case indicated ureteral calculus. A 
small cystic mass lay to the side of the uterus and the rontgenogram 
showed" a shadow along the course of the ureter. Pyelography 
demonstrated a normal pelvis and ureter and an extraureteral shadow 
which operation proved to be a tooth in a dermoid cyst. (Keene 
and Pancoast). (Courtesy Journal American Med. Assoc.) 



156 GYNECOLOGY 

DIAGNOSTIC METHODS COMBINING URETERAL CATHETERIZATION AND 
THE RONTGEN RAY 

Shadow Catheters. — Although the Rontgen ray is the most valuable 
method at our disposal in the diagnosis of ureteral calculus, shadows due 
to other foreign bodies, as, e.g., phleboliths, calcareous lymph-nodes, etc., may 
lie directly along the course of the ureter and lead to confusion (Figs. 
156 and 158). To determine positively whether the shadow is due to a body 
within the ureter or external to it the suspected side should be catheterized, 
the catheter being impregnated with bismuth or some other substance that 
is impervious to the Rontgen ray. The juxtaposition of the catheter and the 
calculus may then be demonstrated ; or a stereoscopic Rontgen ray picture 
may be taken. The shadow catheter plus the Rontgen ray may be of 
value also in identifying renal calculi. 

Pyelography. — Another diagnostic method is that known as pyelography. 
It combines ureteral catheterization, injection into the ureter and kidney 
pelvis of a fluid that is impervious to the ray, and a Rontgen ray picture. It is 
one of the most recently devised and most valuable methods. The technic 
of injection is as follows: A catheter is passed into the ureter of the sus- 
pected side. 2 The cystoscope and catheter are maintained in a fixed position 
while a Rontgen ray plate is placed under the patient and the skiagrapher pre- 
pares to take the picture. A 25 per cent, solution of sodium bromide, a 10 to 
15 per cent, solution of thorium nitrate, 3 or a 10 per cent, solution of collargol 
(colloidal silver) is placed in a burette and is then allowed to run very slowly 
into the catheter until the patient complains of a sensation of fullness in 
the kidney or the flow ceases ; at this instant the skiagraph is taken. The 
burette is now detached and the catheter left in position until the solution 
drains away. 

By means of pyelography the actual outlines of the renal pelvis and the 
ureter are shown. To interpret a pyelograph, the examiner must be familiar 
with the shadow of the normal pelvis and ureter, and with the variations 
in size and shape that occur in health. Surgical diseases of the kidney and 
ureter frequently produce modifications of the normal contour of the kidney 
pelvis and ureter, so that pyelography becomes a valuable aid to diagnosis. 

Pyelography is by far the best method of diagnosing hydronephrosis, 
particularly of the intermittent type. In diagnosing hydronephrosis by 
measuring the quantity of urine in the hydronephrotic sac, or by injecting 
the sac until the patient complains of pain, the sources of error are too evi- 
dent to need elaboration. It may, however, be pointed out that a reflex 

2 For details of pyelography see Keene and Pancoast's paper, Jour. Amer. Med. Assoc, 
1914, lxiii, p. 523. 

3 Burns' method of preparing the thorium nitrate solution is as follows : " To make 
100 c.c. of a 10 per cent, solution, 10 grains of thorium nitrate are dissolved in as little 
distilled water as possible ; to this solution, kept hot on a water- or steam-bath, are added 
30 c.c. of a 50 per cent, solution of sodium citrate, the additions being made in small quan- 
tities, care being taken to shake the solution thoroughly after each addition. At first, after 
the addition of the citrate solution, a white, gummy precipitate is formed, which later be- 
comes granular, but finally dissolves on the addition of all the citrate solution. This solu- 
tion is then made neutral to litmus by the careful addition of a normal solution of sodium 
hydroxid and made up to the required volume of 100 c.c. with distilled water. Upon filtra- 
tion a clear, limpid solution is obtained which is not affected in the least by sterilization." 



EXAMINATION OF THE URINARY ORGANS 



157 



x 



polyuria may be induced at the time of catheterization, and that the hydro- 
nephrotic sac may be partially filled or entirely empty at the time of injec- 
tion. These sources of error may all be overcome by the pyelograph. 

If the presence of a stone is suspected, a picture should be taken prior to 
making the collargol injection, since the pyelograph may obscure the shadow 
cast by the stone. A stone within the ureter may sometimes be brought out 
with greater distinctness by the addition of the shadow of the pyelograph to 
the shadow of the stone (Fig. 159). It may also serve to demonstrate that 
the shadow is that of a _ 

stone within the ureter, 
rather than a phlebolith or 

other foreign body on the : / / / / 

exterior, by reason of the \ \\< 

fact that the ureter around \ N j | / //^ 

and above the stone will • -p 

show dilatation. 

Pyelography often dis- 
closes perfectly the kink in ■ j 
the ureter produced by dis- i __ 
location ofthekidney / / 
downward (Fig. 160). A / / 
picture is first taken with ' I X ■ 
the patient in the recumbent \ 
posture, followed by one 

with the patient standing \- 

upright after she has been / y ' \ 

directed to breathe deeply f I 

and the kidney has been 
dislocated downward. 

A pyelograph may also re- 
veal distortion of the kidney 
pelvis or calyces, as in the 
case of renal tumors or con- 
genital cystic disease of the 
kidney (Figs. 159 and 160). 

Pyelography is a method to be used only by those who are thoroughly 
familiar with cystoscopy and ureteral catheterization, since there is great 
danger of injecting the kidney pelvis to the degree of excessive tension. 
Under the latter circumstances death has resulted. 

Death following pyelography has been ascribed to shock, colloidal silver 
poisoning, colloidal silver embolism, rupture of a hydronephrotic sac, and 
rupture of the kidney pelvis with hemorrhage. 

In most of the fatal cases reported the quantity of solution used exceeded 
the capacity of the kidney pelvis and had been injected with a hand syringe ; 
or the solution used was of such a strength as to be chemically irritating. 4 

4 Manges observes the kidney through a fluoroscope during the injection of the opaque 
solution ; this shows the position of the kidney, and whether or not the solution has reached 
the pelvis. 



Fig. 159. — The rontgenogram failed to demonstrate a calculus. 
The catheter met an obstruction 13 cm. from the ureteral orifice. 
By means of a collargol injection, the calculus was clearly defined 
together with a hydroureter and hydronephrosis. (Keene and 
Pancoast). (Courtesy Journal Amer. Med. Assoc.) 



158 



GYNECOLOGY 



Collargol, which was used by a majority of the investigators in the early 
days of pyelography, has been largely supplanted by the less irritating 
sodium bromide and thorium nitrate solutions suggested by Braasch and 
by Burns. 

Estimating the Functional Activity of the Kidneys — Combined and 
Separate. — The amount of urine excreted from each ureteral orifice may 
be estimated roughly by observing the frequency of the ejections. The 
actual amount excreted from either kidney during a given time may be 
determined accurately by catheterizing the ureter and collecting the urine. 

The total quantity collected 
from one ureter during a 
given portion of time will be 
an index to the activity of 
the corresponding kidney 
from which an estimate for 
the entire twenty-four hours 
may be made, provided the 
ingestion of solids and fluids 
is maintained at stated inter- 
vals and in equal quantities. 

Chrom o-cystoscopy. — 
Since catheterization of the 
ureters may be painful and 
is often undesirable or even 
absolutely contraindicated, 
the method known as chro- 
mo-cystoscopy may be em- 
ployed, and will serve as a 
useful substitute in estimat- 
ing the functional activity of 
the individual kidneys. This 
method is based on the fact 
that if a given amount of 
coloring matter dissolved in 
water is injected into the 
subcutaneous connective tis- 
sue, it will be absorbed into 
the circulation and be eliminated by the kidneys within a specified time and 
to a certain degree in health. The length of time required for the coloring 
matter to appear and the degree to which it tinges the urine are dependent 
upon the activity of the kidneys. 

'Indigo-carmine. — Although other dyes have been used for this purpose, 
that which has proved most satisfactory is indigo-carmine. 

Chromo-cystoscopy not only gives an indication as to the total renal 
activity, but it also enables a fairly accurate comparison of the two sides to 
be made. It serves as a means for locating the ureteral orifices for the be- 
ginner, or for the expert as well when the orifices are hidden and difficult 
to find. 



L .. ______ . . -. . _ _ - 

Fig. 160. — Ptosis of the left kidney with hydronephrosis. The 
catheter met an obstruction 4 cm. from the ureteral orifice. 
Pyelography demonstrated the kink in the upper ureter and the 
distention of the kidney pelvis and calyces. (Keene and Pan- 
coast.) (Courtesy Journal Amer. Med. Assoc.) 



EXAMINATION OF THE URINARY ORGANS 159 

Chromo-ureteroscopy. — The technic of this method is as follows : The 
patient is placed upon the examining table, and the external genitalia and 
buttocks are washed with green soap and warm water, followed by a i : iooo 
bichloride solution. The bladder is now irrigated, and the cystoscopic in- 
strument prepared for the examination. A solution of indigo-carmine, con- 
sisting of 8 eg. of indigo-carmine and 10 eg. of sodium chloride dissolved in 
20 c.c. of water and sterilized, is now injected into the gluteal muscles of 
one side. The injection is made with a fine needle, and as soon as the needle 
is withdrawn the point of injection is covered with an alcohol compress. 
The cystoscopic examination is begun, the ureteral orifices located and care- 
fully observed, the cystoscope being turned first to one ureter and then to 
the other. The bladder must be well illuminated. 

Deductions as to the condition of the kidney are made from two facts : 
First, the time that elapses between the injection and the instant when the 
indigo-carmine first appears at the ureteral orifices ; and, secondly, the in- 
tensity of color that the dye lends to the urine. Indigo-carmine is elimi- 
nated by normally functioning kidneys in from three to twenty minutes. 
The color at first may be a light blue, but it soon becomes darker. In 90 
per cent, of kidneys the color appears either as a light or a dark blue within 
fifteen minutes ; in 61 per cent., within ten minutes. If the urine does not take 
on a light blue color at the expiration of fifteen minutes, or a dark blue at 
the expiration of twenty, serious insufficiency of the renal function is pres- 
ent. If no elimination occurs, either the respective kidney or ureter is 
gravely diseased or the ureter is obstructed. The indigo-carmine test takes 
the place of the ureteral catheter in a large number of instances. It reveals 
clearly obstruction of the ureter of a particular side, or a deficiency in the 
secreting power of a diseased organ, but, of course, it does not differentiate 
between them. Error in the deductions made from the indigo-carmine test 
may arise as a result of a temporary reduction in the ingestion of fluids, 
with its consequent effect on the rapidity of excretion and dilution of the 
urine. This may be avoided by routinely directing the patient to drink two 
glasses of water immediately preceding the examination. If the solution of 
indigo-carmine is not accurately prepared, too much or too little of the dye may 
find its way into the blood. Great care should, therefore, be exercised to use 
the exact amount prescribed. 

If the injection is not made sufficiently deep and into a muscle, absorp- 
tion of the dye may be delayed. When it is especially desirable to avoid any 
error in this regard the injection should be made intravenously. 

Phenolsulphonephthalein. — Another method of estimating the functional 
activity of the kidney is by the injection intramuscularly or intravenously 
of phenolsulphonephthalein (1 c.c. of a solution containing 6 mg. of the drug). 
Healthy kidneys will eliminate 60 per cent, of the drug within two hours ; 
its presence in the urine may be detected by rendering the urine alkaline 
by the addition of a few drops of a 25 per cent, solution of sodium hydroxide, 
which brings out the carmine color. The percentage of elimination is then 
estimated by comparing the shade of the urine with a standard color con- 
trol in the Duboscq colorimeter, or by comparing the color with a series of 
solutions of known percentage. 



160 GYNECOLOGY 

The phenolsulphonephthalein method is one of limited value in estimat- 
ing the function of a particular kidney. This is due to the fact that the 
naked eye observing the ureteral orifice is, of course, unable to detect the 
exact time at which elimination begins or to make any estimate of the 
amount excreted. The urine must be rendered alkaline in order to bring 
out the color. The kidneys may be tested separately by catheterizing both 
sides and allowing the ends of the ureteral catheters to empty into a test- 
tube containing sodium hydroxide. The disadvantage of this latter method 
is, however, apparent at once. 

The particular advantage of the phenolsulphonephthalein test is that 
the injection is practically painless, no more than i cm. of the solution being 
used, and that it is exceedingly reliable as a means of diagnosing the total or 
combined efficiency of both kidneys. In employing the test for this pur- 
pose the patient is directed to drink from 600 to 800 c.c. of water. One c.c. of 
a solution containing 6 mg. of the drug is then injected subcutaneously and 
the bladder immediately emptied by catheterization. At the end of an hour 
the bladder is again emptied by means of a catheter, the urine rendered 
alkaline, and the percentage of elimination estimated. At the end of the 
second hour the patient is again catheterized and an estimation is made 
of the second specimen. If the total elimination for two hours does not 
reach 60 per cent., this is evidence that the combined excretory power of the 
kidneys is deficient. 

That the phenolsulphonephthalein test is valuable used in conjunction 
with the indigo-carmine test is plainly evident ; for example, if the indigo- 
carmine test has shown that one kidney is inactive, a normal elimination of 
phenolsulphonephthalein will indicate that the other kidney is functionally 
sufficient. 

The Blood Urea Test. — An estimate of the functional capacity of the 
kidneys is afforded by a method for determining the blood content of cer- 
tain of the end-products of protein metabolism ; for example, of the total 
non-protein nitrogen, or of one of the following constituents : Urea, creatinin, 
uric acid. Of these, the blood urea test seems to be the most satisfactory. 

The amount of urea in the blood of a normal individual under ordinary 
conditions of life does not exceed about 35 mgm. per 100 c.c. If the func- 
tion of the kidneys becomes impaired, the amount of blood urea increases in 
proportion to the degree of insufficiency. A blood-urea content of over 200 mgm. 
per 100 c.c. with few exceptions portends the early death of the patient. 

Methods for Determining Blood Urea. — The method most generally 
employed is that of Van Slyke and Cullen, or one of the newer modifications 
that are constantly appearing in the literature. Because of the frequent 
changes suggested in the technic of this test and of the other blood chemical 
tests, in the selection of the method the student must be guided by the cur- 
rent literature. As a rule, 5 c.c. of blood removed from a vein suffice for 
the test. 



EXAMINATION OF THE URINARY ORGANS 161 

BIBLIOGRAPHY 

Albarran : Exploration des fonctions renales. Paris, 1905. 

Braasch, W. F.: Pyelography. Saunders, Phila., 1915. Ibid. : "Clinical Data of 
Nephrolithiasis." Sur., Gyn. and Obst, 1917, vol. xxiv, No. 1, p. 8. Ibid. : "Recent 
Observations in Cystoscopic Technic." Annals of Surgery, 1917, vol. lxv, p. 615. 

Braasch, W. F., and Wildner, F. S. : " Pyelography." Int. Abst. of Sur., Feb., 1915, p. 117. 

Burns, E. : " Thorium — A New Agent for Pyelography." J. H. H. Bull., 1916, vol. xxvii, 
p. 157. Ibid. : " The Use of Thorium in Urology and Rontgenology." Amer. Jour. 
Rontgenology," 191 6, vol. iii, p. 482. Ibid. : " Thorium — A New Agent for Pyelog- 
raphy." J. A. M. A., 1915, vol. lxiv, p. 2126. 

Casper and Richter : Functionelle Nierendiagnostik. Berlin, 1901. 

Clark, J. G., and Keene, F. E. : " The Relationship Between the Urinary System and Dis- 
eases of the Female Pelvic Organs." Surg., Gynec. and Obst., 1914, vol. xviii, p. 10. 

Dowdall, G. G. : " Five Diagnostic Methods of John B. Murphy of Chicago." Arch, of 
Diag., 1910, vol. iii, p. 18. 

Eisendrath, D. : " The Effect of Injecting Collargol into the Renal Pelvis." Jour. Am. 
Med. Asso., 1914, vol. lxii, p. 1392. 

Goldberg, B. : " Uber das Verhaltniss von Eiweissgehalt und Eitergehalt in Urinen." Cen- 
tralbl. f. d. med. Wissensch., 1893, vol. xxxi, p. 593. 

Hunner, G. L. : " The Mensuration and Capacity of the Female Bladder." J. H. H. Bull., 
No. 105, Dec, 1899. Ibid. : " Forcible Dilatation of the Kidney Pelvis as a Means of 
Diagnosis." Surg., Gyn. and Obs., May, 1910, pp. 485-493- Ibid. : '" The Significance of 
the Urinary Examination in Women." Amer. Medicine, vol. ix, No. 14, pp. 559-562, 
April 8, 1905. 

Kelly, H. A. : " My Experiences with the Renal Catheter as a Means of Detecting Renal 
and Ureteral Calculi." Am. Jour. Urol., 1904, i, 14. 

Keene, F. E., and Pancoast, H. K. : " The Present Status of Pyelography." Jour. Am. 
Med. Assn., 1914, vol. lxiii, p. 523. 

Kelly and Burnham : Diseases of the Kidney, Ureters and Bladder. Appleton, New 
York, 1914. 

Kelly, H. A., and Lewis, R. M. : " Silver Iodide Emulsion — A New Medium for Skiag- 
raphy of the Urinary Tract." Surg., Gyn. and Obst., 1913, vol. xvi, p. 707. 

Keyes, E. L., and Mohan, H.. " The Damage Done by Pyelography." Amer. Jour. Med. 
Sci., 1915, vol. cxlix, p. 30. 

Kummell, H. : "Modern Surgery of the Kidney: The Achievements of Modern Surgery 
of the Kidney from the Standpoint of Diagnosis and Therapeutics." Surg., Gyn. and 
Obst., 1907, vol. iv, p. 21. Ibid. : " Uber moderne Nieren-Chirurgie, ihre Diagnose und 
Resultate." Berl. klin. Wchnschr., 1906, vol. xliii, 901 ; 952. 

Pilcher, P. M. : Practical Cystoscopy. Saunders, Phila., 1915. 

Rowntree, L. G., and Geraghty, T. G. : " An Experimental and Clinical Study of the Func- 
tional Activity of the Kidneys by Means of Phenolsulphonephthalein," J. Pharmacol. 
and Exper. Therap., 1910, vol. ii, p. 579. 

Thomas, B. A.: " Chromo-cystoscopy in Functional Renal Diagnosis Based upon the Em- 
ployment of Indigocarmin." Penn. Med. Jour., Sept., 1909. Ibid. : " Diagnosis of 
Renal Diseases and Sufficiency." Annals of Surgery, April, 1908. Ibid. : " Uber die 
Chromo-ureteroskopie in der funktionellen Nierendiagnostik." Zeit. f. Urologie, 191 1, 
Band V. Ibid. : " The Results of Two Hundred Chromo-ureteroscopies Employing 
Indigocarmin as a Functional Kidney Test." J. A. M. A., Jan. 18, 1913, vol. Ix, 
pp. 185-188. Ibid. : " The Quantitative Determination of Functional Renal Sufficiency 
by the Duboscq Colorometer ; Indigocarmin versus Phenolsulphonephthalein." Amer. 
Jour. Med. Sci., Sept., 191 1. Ibid. : "The Relative Value of the Various Methods 
for the Determination of Functional Kidney Sufficiency." Penna. Med. Jour., 
Feb., 191 1. Ibid. : "The Value of Chromo-ureteroscopy in Functional Kidney Diag- 
nosis." Surg., Gyn. and Obst., April, 191 1, pp. 345-353- 

Voelcker, F. : Diagnose der chirurgischen Nierenerkrankungen unter Vertwertung der 
Chromo-cystoskopie. 1906, Wiesbaden. 

Young, E. L. : " A New Preparation for Pyelography." Boston Med. and Surg. Asso.. 1915, 
vol. clxxii, p. 539. 



11 



CHAPTER X 
EXAMINATION OF THE ANUS AND RECTUM 

An examination of the anus and the rectum forms a valuable addition to 
the gynecologic examination, and should never be omitted when any symp- 
toms directly referable to these parts are present. If the rectum calls for 
special attention, the initial rectal examination should not be made until sev- 
eral hours after defecation has occurred. In this way the examiner may detect 





Fig. 161. — Examination of rectum — patient in dorsal position, with Tuttle's pneumatic speculum. 

the presence of any abnormal discharge. Ordinarily anal and rectal exami- 
nations are facilitated by giving the patient a preparatory enema. 

In making the examination the patient should be placed in the ordinary 
dorsal or Sims' position (Figs. 160 and 161). Simple inspection will reveal: 
The outlines of the external sphincter ; whether the anus is well tucked up 
or protruding; the existence of a mucous, purulent, or bloody discharge; 
the color of the mucosa and of its surrounding integument, and the pres- 
ence of external hemorrhoids, scars, ulcerations, or fistulous openings. 

Palpation will disclose the presence of tenderness and induration sug- 
gestive of fissure, fistula, or perirectal inflammation. A fine silver probe 
162 



EXAMINATION OF THE ANUS AND RECTUM 163 

should be inserted lightly into any pits, fissures, or adventitious openings 
that may be present, for only in this way can some fistulas be detected. 

The buttc :ks may now be well separated and the patient directed to 
strain slightly, thus exposing the greater part of the anal canal (Fig. 162). 
Dryness and desquamation of the anal mucosa, 
swelling and inflammation of the anal folds, 
fissure, anal polypus, and hemorrhoids will be 
at once revealed. 

To the trained examining finger an anal ex- 
amination will yield valuable information. The 
examiner's hand should be protected by a rubber 
glove ; the finger should be well lubricated and 
introduced very slowly, and with a boring mo- 
tion. The irritability of the sphincter muscle, as 
well as its size, tonicity, and sensitiveness should 
be noted. After passing the external sphincter, 
the finger should be swept around the anal canal, 
palpating the crypts of Morgagni and the pillars 
of Glisson, to ascertain the presence of ulcers or 
hypertrophied papillae, small indurated areas sug- 
gestive of a blind internal fistula, or larger areas 
of induration or fluctuation indicative of peri- 
rectal inflammation or abscess. 

Unless their connective tissue is hypertro- 
phied, internal hemorrhoids cannot be felt. The 

, • j r mi 1 , 11 FlG. 162. — Examination of anus, 

practiced finger, will detect an unnatural dryness buttocks separated, 

or roughness of the mucosa, ulcers, polypi, 

tumors, strictures, foreign bodies, prolapse, and inflammation. Before 
withdrawing the finger from the rectum the coccyx should be palpated be- 
tween the finger and the thumb externally, moving the structure backward 
and forward in order to detect the presence of fracture, dislocation, or un- 





FiG. 163. — Tuttle's pneumatic speculum. 

usual sensitiveness. As the finger is withdrawn the patient is directed to 
bear down. This will frequently cause internal hemorrhoids to protrude 
from the anus, and any blood, mucus, or pus in the rectum will thus be discharged. 
Instrumental examination of the rectum is accomplished with the aid of 
certain specula. For inspecting the anus itself the bivalve speculum de- 
vised by Tuttle is most satisfactory. Tuttle recommends that a small iaryn- 



164 



GYNECOLOGY 



goscopic mirror be used in connection with this instrument, in order to 
obtain a good view of the mucosa covering the upper surface of the internal 
sphincter and the lower part of the rectum. 

For examinations of the rectum and the sigmoid flexure the tubular 
specula, fashioned after the instruments devised by Kelly (Fig. 164) are of 
most value. When they are to be used the patient should be placed in the 
knee-chest position (Fig. 165). With a little practice the entire length of the 
rectum and a part of the sigmoid flexure will be open to inspection. 

The pneumatic proctoscope facilitates the rectal examination, since the 







[65. — Examination of rectum and lower sig- 
moid with proctoscope. 

patient may assume the dorsal or Sims' position. With the longest instru- 
ments of this type the entire sigmoid flexure may be inspected or even the 
lower part of the descending colon. Ordinarily, no anaesthesia is required. 
This instrument gives the best and greatest degree of exposure of any form 
of proctoscope as yet devised. 

Tuttle warns the beginner that the brilliant illumination of the parts 
by an electric proctoscope heightens their color and may lead to false con- 
clusions. It is, therefore, wise, at first, to compare the findings secured by 
artificial light with those obtained by ordinary reflected daylight. Fogging 
of the window of the instrument may be prevented by heating it slightly. 

If the sphincter is relaxed as the air is pumped in for the purpose of 
inflating the canal, air may escape around the instrument ; this may be pre- 



EXAMINATION OF THE ANUS AND RECTUM 165 

vented by applying a coil of wet cotton or gauze about the tube and press- 
ing it firmly against the anus. Before withdrawing the instrument the glass 
window should be taken off and the air be permitted to escape. 

Certain other instruments are useful in making anal examinations. A 
probe eight or ten inches long, made of pure silver, so that it can be bent in 
any direction without breaking, is useful in following up fistulous tracts. 
The instrument should have a handle that is flattened and rough on one 
side, so that the examiner can always determine the direction in which 
the end is pointing. 




Fig. 166. — Kelly's sigmoidoscope. 

An extremely fine probe is often useful in detecting blind internal 
fistulse, and especially in determining the presence of diseases of the crypts of 
Morgagni. A small scoop made of soft copper is very serviceable for re- 
moving hard fecal masses or for freeing the mucosa or ulcerated surfaces of 
discharge. It is a good plan, as a rule, to have at hand a number of appli- 
cators or dressing forceps by means of which the mucosa may be cleansed 
w xth cotton. 

BIBLIOGRAPHY 

Allingham, W. : The Diagnosis and Treatment of Diseases of the Rectum. Wood, New 

York, 1912. 7th ed. 
Earle, S. T. : Diseases of the Anus, Rectum and Sigmoid. Lippincott, Phila., 1914. 
Gaxt. S. G. : Diseases of the Rectum and Anus. Davis, Phila., igo6. 
Piersol, G. A. : Human Anatomy. Lippincott, Phila., 1907. 
Tuttle, J. P. : Diseases of the Anus, Rectum and Pelvic Colon. Appleton, New York, 1912. 



CHAPTER XI 
DISEASES OF THE EXTERNAL GENITALIA 

Cutaneous Diseases. — Erythema and superficial dermatitis may be 
caused by chafing, uncleanliness, leucorrhceal discharge, irritating substances 
in the urine, and varicose veins. 

The symptoms consist mainly of burning and itching. The skin of the 
vulva is reddened and usually moist, and the upper inner surface of the 
thighs may be affected coincidentally. 

The treatment consists in removing, so far as possible, all sources of 
mechanical irritation ; in rendering the urine bland and keeping the parts 
scrupulously clean, and in improving the circulation. Sedative remedies 
may be applied locally. 

The most effectual application consists of a 5 to 10 per cent, solution of 
silver nitrate, followed by zinc ointment. If the patient is excessively fat, and 
the moisture and perspiration are very free, a dusting powder may be em- 
ployed in place of the ointment. Probably the most useful combination con- 
sists of equal parts of tannic acid and lycopodium. Irritating soaps must 
be avoided. 

Herpes. — Herpes simplex, or so-called fever blisters or cold sores, may 
develop at the time of each menstrual period, and have occasionally been 
observed after coitus. In this condition the groups of vesicles are usually 
bilateral. No constitutional symptoms are present, but the patient complains 
of soreness and itching. 

The treatment of herpes consists, first, in thorough and gentle cleansing 
with warm water and Castile soap. The vesicles should be opened with a 
sterile needle and touched with a 5 to 10 per cent, solution of silver nitrate. 
Zinc oxide ointment or stearate of zinc in the form of a dusting powder 
should then be applied. Recurrent herpes of the genitalia should suggest 
careful inquiry into all the habits of the patient, and frequently not only 
extreme local cleanliness but general tonic treatment as well will be required. 

PARASITIC DISEASES 

Ringworm. — Ringworm involving the vulva or the inner surface of the 
upper thighs is best treated by local applications, three or four times daily, 
of liquor potassae chlorinatse (Javelle w T ater). Precipitated sulphur, one-half 
dram to one ounce of petrolatum, may also be applied. At the outset the 
strength of the lotion and of the ointment must be reduced. As many of 
these cases are aggravated by the discharges from the genitalia, vaginal 
douches must be employed. Mercurial ointment, ammoniated mercurial 
ointment, one-half dram of each to one ounce of petrolatum or cold cream, 
may be used, but are generally less effectual than the others mentioned. 

Pediculosis Pubis. — Under the microscope, the pediculus resembles a 
crab, hence the name " crab-louse " commonly applied to it. The finding of 
either the pediculus or its ova (nits) is diagnostic. The pediculus may be 
166 



DISEASES OF THE EXTERNAL GENITALIA 167 

discovered crawling over the skin surface, in the region of the genitalia, or, 
as is generally the case, it may be seen as a small, blackish-brown spot at 
the entrance of the hair-follicle, the head of the insect being buried in the 
root of the hair. The nits are suspended from the hair-shaft, and are 
either of a shiny, pearl-white, or a dull, yellowish- white hue, if the egg is 
dead, hatched out, or killed. Intense itching is present, and numerous scratch- 
marks are seen on the pubes, the lower abdomen, and the thighs. The skin 
not infrequently exhibits a secondary pustular infection. 

The condition is best treated with an ammoniated mercurial ointment, 
from 30 to 40 grains to the ounce of petrolatum, or a mercury bichloride 
and glacial acetic acid lotion, one-quarter grain of the former and twenty 
minims of the latter to the ounce of water. Equal parts of alcohol, ether, and 
a 1 : 500 watery solution of mercury bichloride are also useful. Applications 
of the ointment or of the lotions should be made several times a day. 

Vulvar Adhesions. — Adhesions may occur between the labia majora and 
the labia minora, and between the glans and the clitoris and its prepuce. 
These adhesions are the result either of congenital blending or of desquama- 
tive inflammation which denudes opposed surfaces and is followed by union. 
A great deal of importance has been attached to these adhesions in young women, 
in whom they are said to be a cause of masturbation. The most common 
adhesions are those formed between the glans and the prepuce. They should 
be treated by immediate separation, the glans being peeled out of the pre- 
puce by means of a probe or a grooved director, the parts being dressed 
antiseptically until they have healed over without reuniting. It is prob- 
able that the importance of the condition has been somewhat exaggerated, 
but since a cure is so easily effected, it should never be neglected. 

Vulvitis. — In the young, vulvitis is caused by epidemic gonorrheal in- 
fection, as seen in children's homes and hospitals, or by gonorrhceal infec- 
tion conveyed by the mother or the nurse, or through the medium of 
infected napkins, towels, etc. Thread-worms and uncleanliness may be 
etiologic factors in the vulvitis of children. In adults the condition may be 
produced by repeated gonorrhceal infection, more or less constant contact 
of the parts wdth gonorrhceal pus, irritating discharges from a vesical fistula or 
an ulcerating carcinoma, diabetic urine, too frequent sexual intercourse, or 
masturbation. Streptococcus or diphtheritic infection of the vulva may 
occur in women during the puerperium. The rectal discharge in typhus 
fever and in dysentery may set up a vulvitis. 

The symptoms are a sense of fullness in the affected parts, discomfort, 
and burning and itching. A profuse irritating discharge is present. All the 
symptoms are aggravated by walking. 

The vulva is covered with a mucopurulent or a purulent discharge. The 
vulvar surface is seen to be swollen, reddened, and cedematous. In the 
gonorrhceal vulvitis of children, the vagina is, as a rule, affected coincident- 
ally. In adults the urethra and the vulvovaginal glands, and often the 
cervix as well, are involved. The sebaceous glands of the labia majora and 
the labia minora may be particularly involved, the lesions resembling those 
of acne (follicular vulvitis), and the vulvar mucosa between the follicles 
presenting a normal, or at most but a slightly reddened appearance. To 



168 GYNECOLOGY 

determine the nature of the infection, smears and cultures should be made 
from the surface of the vulva, the vulvovaginal glands, and Skene's tubules. 
An infection in the adult involving simultaneously Skene's tubules, the vul- 
vovaginal glands, and the cervix is almost always gonorrheal in nature. 

In the non-infectious forms, cleanliness is the most important factor in 
the treatment. This may be maintained by means of a vulvar douche of 
sodium bicarbonate and sterile water (one dram to a pint), repeated 
several times a day. Cleanliness combined with appropriate treat- 
ment for the provocative lesions will often effect a cure. Thread-worms, 
diabetic urine, and irritating discharges from the rectum or vagina should 
be dealt with as will be described under the treatment of pruritus, page 170. 

When the inflammation is the result of a Neisserian or other infection, 
the vulva should be kept clean by repeated vulvar douches of mercury bichloride 
1 : 4000, or lysol 0.5 to 1 per cent. Once or twice a day, after the antiseptic 
douche, the parts may be washed with sterile water, carefully dried with 
cotton, and painted with a 25 per cent, watery solution of argyrol or a weak 
solution (1 to 5 per cent.) of silver nitrate. Vaginal douches must be avoided 
unless the cervix is involved. When there is a severe itching or burning, 
hot applications of lead water and laudanum or of witch-hazel should 
be made. As the symptoms subside 1 per cent, of powdered burnt alum 
may be added to the hot applications, if their use has been found necessary, 
or an astringent vulvar douche of zinc sulphate and alum in water (15 
grains of each to 1 pint of water) may be substituted. 

General measures, such as rest in bed, saline laxatives, and refrigerant 
diuretics, are important. The vulvar cleft should be filled with gauze or 
cotton, to catch the discharge and keep the inflamed surfaces apart. When 
there is no longer severe burning or tenderness, a stronger germicidal solu- 
tion, such as silver nitrate, 5 to 10 per cent., may be applied directly to the 
vulva. The opposed surfaces of the vulva should be kept separated, and 
protected either with plain or carbolized zinc oxide ointment, or with a 
dusting powder consisting of equal parts of calomel and bismuth, or of 
equal parts of tannic acid and lycopodium. 

Following gonorrhceal vulvitis infection is likely to remain in Bartholin's 
glands, and special attention should be given them. By means of a blunt 
hypodermic needle, 25 per cent, ichthyol or 25 per cent, argyrol should be in- 
jected into their ducts. Should the disease persist in spite of treatment, 
the glands must be laid open freely and cauterized with phenol or a hot 
silver probe, or dissected out entirely. 

For itching, the following lotion may be used : 

$. Phenolis 3j 

Glycerini f 3ij 

Alcoholis f 3ij 

Aq. rosae q. s. f Siv 

Or the following calamine lotion may be used : 

R . Calamini 3iy 

Zinc, oxidi 3iiss 

Aq. calcis, 

Aq. rosae • aa f 3x. 



DISEASES OF THE EXTERNAL GENITALIA 169 

The therapy of gonorrheal vulvovaginitis in infants and young children 
is difficult to carry out. The child is usually terrified by any attempt at 
treatment, and the parts are so small and inaccessible that many mechani- 
cal difficulties are presented. If the disease is confined to the vulva, the 
task is less formidable, as it is limited to external applications. When the 
vagina also is involved — and this is usually the case — the best plan of local 
treatment is to administer copious douches to the vagina, carried out by means of 
a small, soft-rubber catheter, using a gallon of warm salt or boric acid solution 
(i dram to 2 pints of water) at each application. The douche should be given 
by the mother or nurse as often as two or three times a day, being careful to 
avoid traumatism and endeavoring to gain the child's confidence. Every 
two or three days the cleansing douche may be supplemented by a douche 
of silver nitrate (1 quart) 1 : 1000, followed by salt solution. The keynote of 
the treatment is the maintenance of absolute cleanliness plus occasional 
douching with an antiseptic solution. Instead of silver nitrate, ichthyol 
(5 per cent.) may be used, or the vagina may be flooded with argyrol solution 
(10 per cent.) applied by means of a soft-rubber ear syringe. 

The treatment of vulvovaginitis is often unsuccessful because it is in- 
adequately carried out. The affected parts must be kept clean and free from 
discharge, just as in the treatment of gonococcus conjunctivitis. If a watery 
solution shows signs of being irritating, the antiseptic (ichthyol, argyrol) may 
be combined with glycerine or mineral oil. 

If gonorrheal vaccines were effectual, this would be an ideal method of 
treating the vulvovaginitis of children. The results are, however, only fairly 
satisfactory, but if the case is resistant to local treatment, vaccines should 
be tried. Hamilton has obtained 85 per cent, of cures with vaccines, as com- 
pared with 60 per cent, of cures effected by irrigations. He used stock vac- 
cines, beginning with a dose of 50 million every five days, increasing the 
dose by 10 million at each injection. With larger doses — over 100 million — the 
injection is made at ten-day intervals. In acute cases six injections sufficed. 
Hamilton regards a case as cured when the smears are negative for 
gonococci for four successive weekly examinations, and for two additional 
examinations at intervals of two weeks. 

The average time necessary to obtain a cure in eighty-four cases treated 
by vaccines was a little less than two months. 

If there are other children in the same house or institution, complete 
isolation is advisable. The infected child should have its own individual 
nursing bottles, napkins, etc. No tub-baths should be given, and the cotton 
or gauze used in the treatment should be burned. 

Gangrene. — Gangrene of the vulva is the result of infection with the 
diphtheria bacillus or the streptococcus. It occurs in weakly children or in 
parturient women during the course of a prolonged septic condition. It is 
most prone to follow in the wake of contusions, cedema, or extravasations of 
blood. The parts should be left undisturbed as far as is compatible with 
cleanliness. The general treatment is of the greatest importance. Diph- 
theria antitoxin or antistreptococcic serum should be prescribed. 

Pruritus Vulvas. — Pruritus, or itching of the vulva, may be produced 



170 GYNECOLOGY 

by an excess of certain substances in the blood, such as bile, uric 
acid, urea, sugar, morphine, alcohol, or iodine. It may also occur as the 
result of congestion or stasis of the blood-vessels of the vulva, as seen in 
heart disease, pregnancy, retroversion of the uterus, or uterine tumors. It 
may be a symptom in skin diseases, such as erythema, urticaria, herpes, 
eczema, and trichiasis. In carcinoma of the vulva it is an early symptom. 
Among the other etiologic factors are : Irritating discharges, such as hyper- 
idrosis, diabetic or ammoniacal urine, the leucorrhcea of gonorrhceal infec- 
tion of the cervix or the endometrium, carcinoma of the uterus, or decomposing 
fibroid tumor; rectal discharge, as in purulent and catarrhal inflamma- 
tions; parasites, e.g., pediculi, oxyuris vermicularis, and the leptothrix, 
leptomitus, and oidium albicans; heat (pruritus aestivalis) and cold (pruritus 
hiemalis) ; masturbation. 

The itching of the vulva may be intense ; it becomes worse at night, and 
under the influence of warmth and exercise ; it is exaggerated also during 
pregnancy and at the menstrual periods. Because of an uncontrollable 
desire to scratch the patient avoids society and becomes depressed and 
nervous. Relief may be sought in drugs. 

An examination of the vulvar surface usually discloses one of the local 
conditions just noted. Scratch-marks may be present. In old cases there 
is considerable thickening of the vulvar skin, which becomes leathery, and 
presents a dead white surface, broken here and there by the excoriations 
made by the patient's finger-nails. Urinalysis may disclose the presence of 
sugar, bile, or an excess of uric acid. In every case of pruritus it is very 
important to determine the underlying lesion. In the few instances in which 
none of the causes previously mentioned are found, the disease may be 
regarded as a pure neurosis. 

The treatment of a particular case of pruritus is largely governed by the 
cause that produced it. Whatever method may be selected to relieve the 
immediate suffering, the general health should be investigated, and such 
disorders as diabetes and heart disease should be actively treated. 

Locally the parts should be kept absolutely clean, and a sedative oint- 
ment, powder, or wash applied. If the symptoms are caused by pediculi, a 
solution of mercury bichloride (i : 500), in equal parts of alcohol, water, and 
ether or mercurial ointment will give good results. Pruritus due to the itch 
insect may be treated with sulphur ointment (U. S. P.) or betanaphthol 
(35 grains to 1 ounce of lanolin). 

Pruritus due to pin-worms will yield to rectal irrigations with an infu- 
sion of quassia (1 ounce to 1 pint of water), and to the fluidextract of senna 
and spigelia (^ to 1 fluiddram) every four hours until a purgative effect 
is produced. 

Pruritus caused by trichiasis, that is, the growth of short and stiff in- 
verted hairs, should be treated by extracting the hairs with suitable forceps, 
or their growth should be stopped by electrolysis. 

If an irritating discharge is present, a vaginal douche (sodium bicar- 
bonate and sodium biborate, of each, a half ounce to a gallon of warm water) 
should be administered two or three times a dav, after which the vulva 



DISEASES OF THE EXTERNAL GENITALIA 171 

should be thoroughly dried and the vagina packed with tampons, so as to 
absorb any discharge that may come from the upper genital tract. 

If the urine is highly concentrated, potassium citrate, in full dose, with an 
abundance of water, should be given ; if the urine contains pus, sodium 
benzoate and hexamethylenamine, of each, 5 to 10 grains every three hours, 
combined with such measures as are necessary for the pus-producing lesions, 
will be efficacious. 

Rectal discharges should be controlled by frequent irrigation of the 
rectum with normal saline solution, followed by the injection of two ounces 
of a 25 per cent, solution of argyrol, or of a 2 to 5 per cent, solution of silver 
nitrate. If the discharge comes from a lesion situated far above the anus, 
high irrigation of the colon and the exhibition of intestinal antiseptics must 
be practised. 

After thorough cleansing of the vulva nothing is more soothing than the 
application of silver nitrate, 5 to 15 per cent., followed by the ordinary zinc 
ointment of the pharmacopoeia (5 pe 1 ' cent, of phenol sometimes increases its 
efficiency), or a dusting powder of zinc oxide and zinc stearate may be used. 
Irritated surfaces must be kept apart by the interposition of cotton. 

In very severe cases a strong solution of cocaine (20 per cent.) may be 
used, or a dusting powder of morphine (1 grain) and prepared chalk (2 grains) 
may be rubbed in daily ; or, better still, the patient should be kept in bed and 
hot applications of lead water and laudanum be made. 

Combinations almost innumerable have been devised to relieve the itch- 
ing. In obstinate cases various preparations may be tried in the hope of 
finding one that will be successful. Small obtained the best results from 
turpentine and unguentum petrolatum (1 to 2). Montgomery recommends 
equal parts of alum and sugar, also chloroform in glycerin (1 to 8), or hydro- 
cyanic acid 2 or 3 drops to the ounce of water, or 10 per cent, guaiacol in 
vaseline. Hirst mentions the infusion of tobacco, vinegar, vaginal supposi- 
tories of ichthyol and glycerin, the subcutaneous injection of normal salt 
solution (1 to 3 liters), the Rontgen ray, faradism, and the rapid interrupted gal- 
vanic and the high-frequency static current. Penrose speaks of equal parts of 
prepared chalk and bismuth subnitrate, or a mixture of corrosive sublimate 
(y 2 grain) and emulsion of bitter almonds (1 ounce). Monk states that 
Goulard's extract, menthol, and chloral ointment (5 to 10 per cent.) may be 
effectual. He also prescribes Hofmeister's emulsion : 

R. Potassii bromidi 3ij 

Lupulini 3ij 

Hydrargyri chloridi mitis 3x 

Ol. olivse f 3 xx 

Dudley employs pure phenol or pure ichthyol and an ethereal solution 
of iodoform. Noble asserts that nothing relieves the itching of a dermatitis 
better than black wash and bismuth. When pruritus is a symptom of a 
primarily cutaneous lesion of the vulva, the disease, whether it be eczema, 
intertrigo, or some other skin affection, requires the same treatment as when 
it occurs elsewhere in the body. 

In some cases pruritus cannot be ascribed to any demonstrable affection, 
and it may then be regarded as a neurosis and treated accordingly. 



172 



GYNECOLOGY 



In many instances the diet will require regulation. The patient should 
avoid highly seasoned or nitrogenous food, as well as the prolonged use of 
or addiction to certain drugs, such as morphine, quinine, and iodine. Alco- 
hol must also be forbidden. 

Hyperesthesia of the Vulva. (See Vaginismus, page 194.) 





Fig. 167. — Elephantiasis of vulva, (After Allbutt, Playfair and Eden.) (McMillan & Co. Ltd.) 

Kraurosis vulvae is a rare condition, characterized by atrophy and shrink- 
age of the vulvar parts. It is usually preceded by obstinate pruritus. Its 
most common symptoms are intense itching and interference with sexual 
intercourse. Treatment is usually of no permanent benefit. Relief from 
pain and pruritus may be obtained by the use of local applications (see 
Pruritus). Gradual dilatation of the vaginal orifice or surgical measures to 
relieve the contractions are usuallv inadvisable. 



DISEASES OF THE EXTERNAL GENITALIA 



173 



Elephantiasis of the Vulva. — Elephantiasis is a condition of brawny 
oedema and hypertrophy (Fig. 167). The lesion is due to a lymphatic obstruc- 
tion which may be caused by syphilis or the filaria sanguinis hominis. 
There are usually secondary infection and inflammation of an erysipelatous 
type. Occasionally an erysipelatous inflammation (streptococcus erysipe- 
latis dermatitis) appears to be the primary lesion. Uncleanliness predis- 
poses to the disease. The symptoms are due to mechanical irritation, and 
are most evident in walking and during sexual intercourse. The labia 
majora and minora are hypertrophied, pigmented, indurated, and oedematous. 




Fig. 168. — Chancre of vaginal introitus. (University Hospital.) 



Excoriations or warty outgrowths may appear upon the surface of the vulva. 
An offensive serous discharge is present. 

The treatment is more or less unsatisfactory, unless the disease is dis- 
tinctly confined to the vulva. When the latter is the case, the hypertrophied 
parts may be excised with as wide a margin as possible and the wound closed 
by plastic repair. If operation is not undertaken scrupulous cleanliness and the 
use of a dusting powder or a sedative ointment may help to make the 
patient more comfortable. 

Venereal Sores. — The appearance of venereal lesions in the female 
differs somewhat from that in the male. Neither the chancre nor the 
chancroid is so constant in form. Each may be modified by the personal 
cleanliness of the woman and by her habits. Associated with the venereal 



174 



GYNECOLOGY 



lesion, not infrequently there are oedema and induration of the labia majora 
produced by bruising of the vulvar parts during coitus and the use of strong 
disinfecting solutions. 

Chancre. — Chancre of the vulva is so rarely observed that exact infor- 
mation as to its appearance is lacking. For that reason, all cases should be 
described minutely and note made of variations in form. The primary sore 
in women may be considerably modified by the personal cleanliness of the 
woman and her habits. The most frequent seat of chancre, it is said, is the 
labia majora ; the fourchette, nymphse, clitoris, and mons veneris being next 
in frequency in the order named. 

On a skin surface as, e.g., the labia majora, induration develops in about 

a week and is usually parchment- 
like. On modified skin surfaces, 
" near " mucous membranes, in- 
duration may be absent. The pri- 
mary sore is smaller and clears up 
more rapidly in women than in 
men. 

The chancre usually appears 
as a superficial round or oval ero- 
sion, having a dusky red areola, 
and a purplish raw surface, in the 
center of which there is a gray 
false membrane that discharges a 
small quantity of sero-sanguine- 
ous fluid (Fig. 168). 

The chancre often takes the 
form of an indurated papule. It 
consists of a hard, elevated, dusky 
red tubercle, sharply defined from 
the surrounding tissues, having a 
dry surface whose height is fre- 
quently augmented by layers of 
exfoliated epithelium. The 
chancre may be deep enough to 
involve the true skin or even the 
subcutaneous tissues (Fig. 169), 
and in such cases a chancrous 
ulcer may form ; the latter may be superficial or deep, with sloping edges 
and covered with a gray false membrane and a sero-sanguineous discharge. 
The primary sore in women probably occurs more often on the cervix 
than is usually believed. The diagnosis is confirmed by identification of 
the treponema pallidum in suitably stained preparations, or by means of 
fresh smears examined by the dark-field microscope. The Wassermann re- 
action is always indicated in genital lesions as an aid in diagnosis. 

Secondary syphilitic lesions of the vulva are seen somewhat frequently. 
A papular syphilide developing upon the vulva soon exhibits an abraded 
and secreting surface, and may be partly or completely covered by a gray, 




FlG. 169.— Gumma of vulva, with secondary infection and 
ulceration. (Philadelphia Hospital.) 




FlG. 170. — Condylomata lata, secondary syphilis, surrounding vulva. 
(After Power and Murphy.) (Courtesy Potter & Stoughton.) 



DISEASES OF THE EXTERNAL GENITALIA 



175 



adherent, offensive pseudomembrane. This is known as a mucous patch. 
Sometimes the moist papule takes on a distinct papillary overgrowth (con- 
dyloma). Condylomata (Figs. 170 and 171) appear as elevated, flat, raw 
surfaces. The cellular infiltration is so abundant that the papillary nature 
of the growth is but imperfectly manifested, and can be observed only on 
careful inspection. When the mucous patch preceding the condyloma has 
developed from a large papular syphilide, the elevated surface varies in size 
from that of a shirt-button to a penny. 

Tertiary syphilitic lesions of the vulva are rare, and usually manifest 
themselves in the form of gumma of the labia majora (Fig. 175). The lesion 




Fig. 171. — Condylomata lata of the vulva and anus; on the latter they pre- 
sent a papillomatous or vegetative appearance. (After Taylor.) C Courtesy Lea 

& Febiger.) 



shows a tendency to break down and suppurate, producing serpiginous 
ulcers with grayish, ragged floors. 

The Treatment of Syphilitic Eruptions. — In these eruptions the general 
treatment is of the utmost importance, but will not be discussed here. No 
local treatment for chancre is absolutely necessary ; if the surface is hard 
and indurated and fairly dry, it may be protected with a mild ointment of 
ammoniated mercury (20 grains to 1 ounce of zinc oxide ointment) ; if the 
surface is moist, it may be bathed with 1 : 4000 bichloride solution and dusted 
with equal parts of acetanilide, boric acid, and calomel. The patient should, 
of course, be warned of the contagious nature of the infection. Mucous 
patches and condylomata should be painted with silver nitrate (5 to 10 per. 



176 GYNECOLOGY 

cent.) and dusted with iodoform, aristol, or bismuth subiodide. One of the 
best local applications for condylomata is the following: 

R. Hydrarg. chloridi mitis gr. xl 

Ac. salicyl gr. x 

Ac. boric gr. xxx 

Pulv. alum, ex 5j. 

For tertiary syphilitic lesions a mild germicidal protective, consisting of 
either calomel or ammoniated mercury (20 grains to 1 ounce of boric acid 
ointment) may be applied several times daily. 










Fig. 172. — Syphilis (secondary) of the vulva and anus. (Philadelphia Hospital,) 



Chancroid. — Chancroids of the vulva usually affect the area immediately 
surrounding the vaginal orifice, but they may also occur upon the cervix. 
Chancroids in women are usually more extensive than in men. The ulcera- 
tions present a punched-out appearance, and the edges are undermined 
(Fig. 176). Secondary infections are quite common, and may be repeated 
indefinitely unless careful preventive measures are taken. 



DISEASES OF THE EXTERNAL GENITALIA 177 

A chancroidal ulceration of a chancre may occur, or the chancroid and 
the syphilitic infection may occur coincidentally, the lesion of the first dis- 
appearing before the second one develops. When the lesions are combined, 
they may be indistinguishable, the only indication pointing to a chancre 
being the induration. 

Treatment of Chancroid. — Chancroidal ulcers should be immediately 
cauterized with nitric acid, acid nitrate of mercury, or phenol. When the 
lesions are small, the previous application of cocaine may be sufficient to 




: 




Fig. 173. — Syphilis (secondary) of the vulva and anus. (Philadelphia Hospital.) 

relieve pain. In extensive cases, or when the patient is nervous, nitrous 
oxide or a general anaesthetic must be employed. After cauterization the parts 
should be washed with a 1 : 2000 bichloride solution and a dusting powder 
of iodoform applied. The odor of iodoform may be disguised or kept at a 
minimum by carefully limiting its application to the ulcerating surfaces, or 
by mixing it with equal parts of powdered roasted coffee, or with 4 minims 
of the oil of peppermint or the oil of rose to 1 ounce of the powder. Aristol 
or iodol, or the preparation suggested by Knowles (calomel, 20 to 40 grains; 
salicylic acid, 10 to 20 grains; zinc oxide, 30 grains; and talcum, 1 ounce) may 
be used if it is found inexpedient to use the iodoform. The dressing should 
12 



178 



GYNECOLOGY 



be repeated several times a day, and the vulvar cleft kept packed with a 
layer of absorbent cotton held in place by a T-bandage. 

After healthy granulations have appeared, a powder consisting of equal 
parts of acetanilide, boric acid, and calomel may be used. If the discharge 
is profuse, powdered tannin may be added to the dusting powder in the pro- 
portion of i to 4. If the granulations are exuberant, the solid stick or a strong 
solution of silver should be employed. 

In serpiginous cases, prolonged sitz-baths, a wash of nitric acid (1 
dram) and water (1 pint), or hot compresses of bichloride solution (1 : 5000) 
or of lead- water and laudanum, may be used. After healthy granulations 
have appeared in extensive cases, a stimulating solution of the balsam of Peru 
and water (1 to 8) will be fo-und advantageous. Throughout the treatment 

emphasis should be laid upon 
the importance of observing 
scrupulous cleanliness by the 
use of soap and water. 

The general condition of 
the patient should receive 
careful attention. In these 
cases iron, quinine, and strych- 
nine, and cod-liver oil are 
often of service. 

At the first appearance of 
the symptoms of bubo the 
patient should be confined to 
bed and an ice-bag applied to 
the affected groin. If the pa- 
tient must be about, an oint- 
ment made of equal parts of 
ichthyol, mercury, belladonna, 
and iodine should be applied 
to the affected region. A snug 
bandage should be so placed 
as to exert firm, equable 
pressure upon the in- 
flamed gland. If suppuration is imminent, the entire gland should be extir- 
pated without rupture and the incision closed. If enucleation of the gland 
is not feasible, it should be incised, curetted, swabbed with pure phenol, 
and drained. 

Venereal Warts (Condylomata Acuminata). — Venereal warts result from 
uncleanliness or from the irritation produced by gonorrheal discharges. They 
are also associated at times with secondary syphilitic lesions. 

Venereal warts appear in the form of papillary excrescences, either as a 
single discrete group or as a coalescent, cauliflower-like mass (Fig. 177). 
They may occur on the vulva, mons veneris, perineum, or anus, and are also 
occasionally found in the vaginal vault and upon the cervix. In the pregnant 
they grow rapidly. They usually present a purplish-red color. The surface 
is moist, and divided into small projections that have pointed ends 
(condylomata acuminata). 




Fig. 174. — Syphilis (secondary) of the vulva and anus 
delphia Hospital.) 



(Phila- 



DISEASES OF THE EXTERNAL GENITALIA 179 

The symptoms range between actual discomfort and pain. Usually they 
simply interfere mechanically with walking or with intercourse, but when 
inflamed, they become painful, and at times give off a thin and highly 
irritating discharge. 

The treatment is based on the observance of absolute cleanliness and the 
application of antiseptics. If the patient is syphilitic, general treatment is 
required. The parts should be washed frequently with bichloride (i : 2000), 
followed by normal salt solution. After drying, a dusting powder of equal parts 
of tannic acid and lycopodium, or boric acid, 20 to 40 grains, calomel, 15 to 
20 grains, calcium, 1 dram, may be found useful. 





/ 



Fig. 175.—- -Gumma of the vulva, tertiary syphilis. (Philadelphia Hospital.) 

Small outgrowths may be destroyed by nitric, chromic, or acetic acids or 
pure formalin. Before applying these remedies the surrounding skin must be 
protected with vaseline. The acids or the formalin should be applied with 
a glass pencil. Larger masses should be excised, and the wound closed 
with silkworm-gut sutures. 

Individual warts may at times be removed by ligation with fine silk or 
by freezing with a spray of ethyl chloride. Associated or provocative diseases, 
such as syphilis, gonorrhoea, and elephantiasis, must receive suitable attention. 

(Edema of the vulva occurs as the result of intrapelvic pressure from the 
head of the foetus, tumors, pelvic exudates, and infiltrations. It may be 
unilateral or bilateral, the latter being most frequently the case. It may also 
be part of a general oedema due to heart, kidney, or liver disease. CEdema of 
the vulva may be a precursor of elephantiasis, especially if the latter is also 
present in the lower extremities. When oedema is of long duration, hyper- 
trophy of the cutaneous papillae, with the formation of wart-like excrescences, 



180 



GYNECOLOGY 




occurs. If the cause is evident, the indications are plain : The removal of 
pelvic tumors, the absorption of pelvic exudates, the stimulation of a fail- 
ing heart, and of impaired renal or hepatic function. 

Varicose Veins of the Vulva. — Pregnancy, pelvic exudates, pelvic tumors, 
retroposition of the uterus with adhesions, straining at stool, prolonged 
standing, heavy work, and circulatory weakness are among the causes of 
this condition. Varicosities are usually found in the labia majora, but other 
parts, including the vagina, may be involved. 

The patient complains of itching and burning or of a sense of discom- 
fort or weight. An elongated, knotty, bluish enlargement, made up of 

dilated and tortuous veins, is pres- 
ent. Upon palpation the mass re- 
sembles a bag of earth-worms (Fig. 
178). The condition ranges from a 
slight distention of the vulvar veins to 
a tumor as large as the foetal head. 
The underlying or causative lesion 
must, if possible, be corrected. If 
operation is inexpedient, the enlarged 
veins should be supported by means 
of a vulvar pad. In some cases relief 
can be obtained only by excision. 
During pregnancy the patient should 
assume the recumbent position as fre- 
quently as possible. 

Haematoma of the vulva is caused 

by the subcutaneous rupturing of 

varicose veins from increased tension 

during pregnancy or labor, or as the 

result of direct trauma, as by a fall or 

a blow. It is usually unilateral (Fig. 

179). The symptoms consist of sudden 

pain in the affected part, with rectal or 

vesical tenesmus. Later there is also a 

feeling of fullness, and if suppuration 

occurs, as is likely after labor, the 

symptoms of abscess appear. Examination discloses a purplish, globular 

tumor that may be as large as the foetal head. It is tense and elastic at first, 

but later, as the fluid is absorbed, it becomes doughy to the touch. 

During the period of active bleeding, treatment consists of rest in bed 
and the application of an ice-bag or a firm compress. Later hot fomenta- 
tions may effect the absorption of the extravasated blood. If the haematoma 
persists, or if suppuration seems imminent or has occurred, a free incision 
should be made and the cavity packed with gauze and allowed to heal 
by granulation. 

Hypertrophy of the vulva, in part or as a whole, may be a congenital 
or an acquired lesion. It may accompany or follow oedema, and may 
constitute a form of elephantiasis. It is said to affect the labia minora, par- 




FiG. 176. — Chancroid. 



DISEASES OF THE EXTERNAL GENITALIA 



181 



ticularly in patients who practice masturbation. When the latter struc- 
tures alone are involved, especially if unusual pigmentation also exists, 
masturbation may be suspected. A colossal hypertrophy of the nymphae is 
observed in some orientals, the Hottentots, and the Bushmen. This condi- 
tion is known as the Hottentot apron. 

Carcinoma of the Vulva. — Primary carcinoma is usually of the squamous 
type — epithelioma (Fig. 180). It may be preceded by kraurosis, leuco- 
plakia vulvae, papillomata, 
or some form of trauma, 
or there may be no prior 
lesion. Secondary carci- 
noma of the vulva results 
from a malignant growth 
higher in the genital tract, 
and may be of the cylin- 
dric-cell variety (adeno- 
carcinoma). The growth 
begins in the sulcus be- 
tween the labium majus 
and the nymphae, upon 
the clitoris, or in the peri- 
urethral mucosa of the 
vestibule. It occurs with 
great frequency between 
the ages of sixty and 
seventy years, and is 
rarely seen in the young. 
(In 331 cases collected by 
Rothschild, only 11 were 
under thirty-one years.) 

The affection first ap- 
pears as a small, indur- 
a t e d, elevated nodule. 
Later inflammation and 
superficial ulceration occur. 
The surface is elevated and 
granular, and the adjacent 
tissues become thickened 
and indurated. The oppos- 
ing surfaces of the vulva may develop a carcinomatous growth as the 
result of contact. Pruritus is the most common early symptom, but is not 
characteristic of the disease. Early subjective symptoms may be absent. 
Later, when infection has occurred, pain is more or less constant. At 
about this time the inguinal or femoral (or both) glands on the affected 
side become enlarged ; in some cases this occurs much earlier. There is a 
serous, offensive discharge, and slight hemorrhage is observable. After the 
growth becomes extensive and ulceration has occurred the symptoms are all 
intensified and general ill-health and cachexia supervene. 




jH 



s 



FlG. 177. — Venereal warts. 



182 



GYNECOLOGY 



It is important to make a diagnosis of the condition in its earliest stage. 
To this end any suspected lesion should be immediately excised and subjected 
to microscopic examination. It is to be differentiated from lupus, which appears 
at an earlier age, progresses very slowly, and causes but little pain (Fig. 
181). Instead of single, hard nodules, as in carcinoma, there are multiple 
soft growths. In lupus the discharge is not putrid, the ulceration tends to 
undergo cicatrization, healthy skin is frequently found between neighboring 
lesions, and the inguinal glands are not, as a rule, involved. 




FlG. 178, — Varicose veins of the vulva. (Kelly and Aoble's Operative 
Gynecology. W. B. Saunders Co.) 



The first step in the way of treatment in early cases consists of opera- 
tion. The carcinomatous area should be excised en bloc with the neighbor- 
ing lymphatic glands, a wide margin of healthy tissue being allowed to 
remain. The wound should be closed by flaps from the adjacent skin areas. 
If there is the least suspicion of enlargement, or in any case in which the 
disease is advanced or has existed for some time, the inguinal glands on both 
sides must be removed. In advanced cases, dissection of the entire super- 
ficial and deep inguinal and femoral lymphatic chain, by the method of 
Basset, as recommended by Taussig, should be adopted. The latter does 
this on both sides, as the first one of a two-stage operation. Two weeks 
later he performs excision of the vulvar tumor with the cautery knife. In 



DISEASES OF THE EXTERNAL GENITALIA 



183 



very old patients, and when surgical interference is dangerous, the Rontgen ray 
and radium may be used. When operation is undertaken in greatly advanced 
cases, supplementary treatment with the Rontgen ray or radium may be of 
value. (See Chapter XL.) 

Sarcoma of the vulva usually affects the labia majora. It begins as a 
hard, round nodule that is brown or black in color (Fig. 182). It grows 




Fig. 179. — Hematoma of vulva, occupying left labium majus and ex- 
tending downward to perineum. Patient fell astraddle a chair. 
(Kelly's Operative Gynecology. D. Appleton & Co.) 



rapidly and ulceration and involvement of the inguinal glands occur late. 
The disease is usually fatal. Death results from metastasis by way of the 
veins. The diagnosis can be made only from the microscopic findings. Early 
excision of the affected area and radium offer the only hope of cure. 

Tuberculosis of the vulva (lupus) is a rare condition. It occurs often 
before puberty, but more frequently between twenty and forty, and occa- 
sionally later in life. The lesion is produced by the tubercle bacillus, and 
is practically always secondary to genital tuberculosis higher up or to pul- 



184 



GYNECOLOGY 



monary tuberculosis. Early in the disease nodules, varying in size from a 
pinhead to a bean, are seen embedded rather deeply in the skin. They 
present a red, brown, or a yellow-red color. Later they enlarge and undergo 
cheesy or colloid degeneration. Finally ulceration takes place. The ulcers 
are soft and usually superficial in nature, but they may be deep, causing 
fistulous communications between the vagina and the surrounding parts. 
The ulcerated areas are the seat of bright red granulations, bleed easily, 
and are covered with pus which does not have an offensive odor. Cicatriza- 
tion occurs irregularly, and may produce stricture or stenosis of the urethra, 
vagina, or rectum. There is little pain, and the growth is very slow. 




I 





FlG. 180. — Epithelioma of vulva, indurated fungoid ulcer. . (Carnett from Martin.) 
(Courtesy Lea & Febiger.) 



The diseased area should be cauterized thoroughly, and then excised, 
leaving a wide margin of healthy tissue. The Finsen rays and cauterization 
with caustic potash or a paste of pyrogallol (40 per cent.) may be of benefit 
in some cases. 

Rodent ulcer is a term applied to a particular form of chronic ulceration 
of the vulva. It occurs especially in prostitutes, and syphilis seems to be a 
predisposing factor, although its active syphilitic nature is denied. In 
twenty cases observed by Fisichella during a period of six years, the Was- 
sermann reaction was positive in all. The etiology and identity of this 
disease are somewhat shrouded in doubt, but the clinical pathologic picture 
described may be designated as rodent ulcer, esthiom'ene, etc. The disease 



DISEASES OF THE EXTERNAL GENITALIA 



185 



is regarded by some as identical with lupus or tuberculosis of the vulva, and 
in some cases tubercles have been demonstrated in the ulcers. Such in- 
stances are, however, regarded as secondary infections, since, as a rule, no 
specific elements of any kind can be found in the ulcerated areas. 

The underlying cause of the lesion is believed to be a blocking of the 
lymph-channels of the vulva following extirpation or inflammation of the 
inguinal nodes. The connective tissue about the ulcerated areas is frequently 
hypertrophied and cedematous. The ulceration usually begins about the 






FlG. 181. — Lupus of vulva, a pre-ulcerative or infiltrative stage. (After Bender.) 



fossa navicularis, and extends by a serpiginous course to the lateral walls 
of the vagina, urethra, labia, and rectum, producing, often in the later stages, 
fistulous tracts. 

The parts should be kept scrupulously clean. The general health should 
be improved. Ulcers and fistulous tracts should be cauterized with nitric 
acid or the actual cautery at a dull red heat. Antisyphilitic or mixed treat- 
ment should be prescribed, and in some cases of supposed rodent ulcer has 
been of marked benefit. In three cases observed by Fisichella salvarsan 
effected a rapid cure. In rebellious cases radium may be tried. 

Fibromyoma of the vulva affects by preference the labia majora, and 
presents the same structural features as fibromyoma elsewhere in the body. 



186 



GYNECOLOGY 



The symptoms are the result of mechanical interference. The condition is 
ext: emely rare (Fig. 183). The tumor should be removed by operation, and 
the wound closed by plastic repair. 

Lipoma of the vulva is most often situated in the labia majora or on the 
mons veneris, and resembles lipomatous tumors found in other parts (Fig. 
184). Excision of the growth with plastic repair is indicated. 

Sebaceous cysts may form in the larger and smaller labia. They appear 
as small, yellowish elevations. The treatment consists of excision. 

The Vulvovaginal Glands — Inflammation of the Ducts and Abscess. — 
Inflammation of the ducts of the vulvovaginal glands is usually of gonor- 
rhoeal origin, but it may be due to other infections, notably of the colon bacillus 

and the tubercle bacillus, ex- 
tending from the surface. 
Tuberculous vulvovaginal 
abscess is not infrequently 
observed in phthisis. In 
gonorrhceal inflammation of 
the duct the orifice is sur- 
rounded by a red, slightly 
elevated spot, known as the 
gonorrhceal macule. Pres- 
sure over the course of the 
duct will express a drop of 
pus. Inflammation of the 
ducts of the vulvovaginal 
glands may lead to the for- 
mation of a retention cyst or 
to an extension of the infec- 
tion to the gland substance, 
with the production of an 
abscess. Abscess of the vul- 
vovaginal gland is mani- 
fested by severe pain and 
marked swelling and oedema 
of the surrounding parts. 
The swelling may extend 
even to the anus. Fluctuation appears first upon the inner surface of 
the labium, and, if the pus is not evacuated by incision, it finally makes its 
way through several fistulous openings below the orifice of the duct. These 
openings may keep on discharging indefinitely. 

The treatment of an infection of the ducts of the vulvovaginal glands 
consists in keeping the duct patulous and in injecting an antiseptic solution 
by means of a blunt hypodermic needle. Before introducing the needle, all 
the pus should be expressed from the gland and the orifice wiped clean. 
The needle should then be passed gently as far as it will go, and the solu- 
tion injected, the needle being held in position for a few seconds and the 
duct compressed about the barrel. As a rule, only one or two drops can be 




FlG. 182. — Sarcoma of left labium minus (Hirst's Obstetrics. 
W. B. Saunders Co.) 




Fig. 183. — Fibromyoma of vulva, (After Collyer.) American Journal of 
Obstetrics. 



DISEASES OF THE EXTERNAL GENITALIA 



187 



injected. This treatment should be repeated daily. Pure ichthyol (25 per 
cent.), solution of argyrol, or 5 per cent, silver nitrate may be used. If the 
treatment is not successful, the duct of the gland should be laid open freely 
and cauterized, or the duct and the entire gland should be dissected out. 

In the early stage an abscess of the vulvovaginal gland (Fig. 185) may 
be treated by means of hot fomentations. As soon as fluctuation appears, a 
free incision should be made and the entire cavity swabbed out with pure 
phenol and the cavity packed with gauze and allowed to heal by gran- 
ulation. When there is a tendency 
for these abscesses to recur, the . 
glands should be totally excised. 

Cyst of the vulvovaginal 
glands either occurs as the result 
of an occlusion of the duct by an 
inflammatory process, or is due 
to a thickening of the glandular 
secretion. The symptoms of vul- 
vovaginal cysts are usually the 
result of mechanical interference 
with sitting, walking, or sexual 
intercourse. Vulvovaginal cysts 
vary in size from a walnut to a 
child's head. When they reach 
the dimensions of an egg or even 
larger, the mucosa to the inner 
side of the labium, overlying the 
surface of the cyst, is consider- 
ably thinned. The cyst contents 
are clear and colorless, or may 
be yellow or a turbid chocolate 
color from admixture with blood. 
Vulvovaginal cysts must be dis- 
tinguished from inguinal hernia, ■ 
hydrocele of the canal of Nuck, 
and cysts of old hernia sacs. In 
these conditions the enlargement 
is situated more to the upper and 
outer part of the labium majus, 
and is connected with the exter- 
nal inguinal ring. 

Vulvovaginal cysts should be excised. This is best done while the 
tumor is small, since in advanced cases the vulvar mucosa becomes so 
thin and attenuated, and the cyst so deeply attached that considerable 
dissection is necessary to effect its removal, and the wound may have to be 
packed and allowed to granulate. This is due to the fact that the flaps of 
thinned-out mucosa are poorly supplied with blood and show a tendency to 
slough. If, for any reason, excision of the gland is not feasible, a free in- 




FlG. 184. — Lipoma of right labium majus. 



188 GYNECOLOGY 

cision may be made, and as much of the gland wall as possible cut away 
with scissors, the interior swabbed with pure phenol, packed with gauze, and 
allowed to heal by granulation. 

Injuries of the External Genitalia. — The vulva is often the seat of in- 
jury and violence. It may be injured as the result of a fall astride a fence, 
the edge of a bath-tub, the arm of a chair, or the frame of a bicycle ; it may 
be lacerated by a fall upon some protruding object, such as the paling of a 
fence or the handle of a rake, or by sitting upon a knife, a pair of scissors, 




Fig. 185. — Abscess of left vulvovaginal gland. Kelly's Operative Gynecology (D. Appleton & Co.). 

or a crochet-hook. The vulva may be seriously bruised and lacerated by the 
horns of a cow or as the result of a kick, or by violence inflicted during 
coitus. Insane persons sometimes mutilate the vulvar region. The wounds 
may be incised, lacerated, contused, or punctured. Such injuries are accom- 
panied by the usual symptoms of pain and hemorrhage. The latter is fre- 
quently profuse, owing to the vascularity of the parts affected. It may be 
partly or entirely concealed, forming a hematoma that appears as a dark, 
bluish-red mass, occupying the greater labium or the vaginal wall. 

Injury during the first coitus sometimes produces alarming hemorrhage. 



DISEASES OF THE EXTERNAL GENITALIA 189 

The rape of young girls or infants by adults may result in injury or laceration 
of the vagina and perineum, or even in a tear of the rectovaginal septum or 
the sphincter. Bilateral splitting of the urethra as far up as the bladder, 
with the production of a vesico-urethrovaginal fistula, also a rupture of the 
posterior vaginal fornix, has been observed. The injury must be dealt 
with according to its nature and according to the character of the 
injuring force. Clean incised or punctured wounds may be disinfected 
and immediately closed with catgut or silkworm-gut sutures. Contused 
and lacerated wounds in which submucous and subcutaneous hemorrhages 
are present are best treated at 
first by local applications of ice 
and antiseptic compresses. After 
hemorrhage has ceased and the 
danger of infection no longer 
threatens, hot applications may 
be substituted in order to favor 
the absorption of extravasated 
blood. If this does not occur 
promptly and rapidly, the accumu- 
lated mass may be opened by free 
incision, the clot turned out, and 
the cavity closed with drainage. 

Pudendal Hernia. — Disten- 
tion of either labium majus from 
a complete inguinal hernia may 
occur, the condition being anal- 
ogous to a scrotal hernia in the 
male. A tumor of the affected 
part is formed that has the usual 
characteristics of a hernia, which 
need not be detailed here. 
Marked examples of pudendal 
hernia are not nearly so frequent 
in the female as extensive scrotal 
hernia is in the male. Inguinal 
hernias in women are more apt 

tr» bp small Hict^nrlin cr n-nUr tV-i^ FlG - l86 - — Extreme cystic distention of vulvovaginal gland. 
TO De Small, aiStenamg Only tne simulating a labial hernia. 

upper part of the corresponding 

labium majus and the corresponding area of the mons veneris. A rare form of 
hernia, known as perineal, manifests itself in the form of a protrusion of gut or 
omentum through a weakened area in the perineal floor, which is located either 
between neighboring fasciculi of the levator ani and the coccygeus muscle, or 
at the site of the rectal or vaginal sheath, which penetrates and is sur- 
rounded by the muscles and fascia of the perineal floor. In the most fre- 
quent form the protrusion descends along the vagina, forming a tumor to 
one or the other side of the vaginal orifice (Fig. 186). It may present all the 
usual characteristics of a hernia, being tympanitic on percussion, showing a 
marked impulse on coughing, and disappearing when the patient assumes 



190 GYNECOLOGY 

the recumbent posture or when suitable manipulations are instituted. Peri- 
neal hernias must be distinguished from cystocele and rectocele, vaginal 
cysts, the ordinary enterocele associated with the bladder or rectum, diver- 
ticula in prolapse, etc. In a majority of instances the treatment is surgical. 
The operation consists in dividing the skin and fascia over the tumor, ex- 
posing the sac, separating it from surrounding structures, opening the sac, 
and releasing the intestine or omentum, excising the sac, and bringing the 
margins of the wound together by means of chromic or silkworm-gut 
sutures. When the hiatus in the pelvic floor is very extensive, any attempt 
to close the hernial ring may appear impracticable. In such cases, and in those 
in which, because of age or illness, operation is inadvisable, some form of 
pad and perineal strap may be found useful. 

BIBLIOGRAPHY 

Allbutt, Playfair, and Eden : System of Gynecology. MacMillan Co., N. Y., 1906. 
Bidwell and Carpenter : " Gonococcal Infections in Childhood." Brit. Jour. Children's 

Diseases, No. 10, 1904. 
Breisky: " Uber Kraurosis Vulva?." Zeitschrift f. Heilkunde, 1885, vi, 69-80. 
Bulkley, K.. "Tuberculosis of the Vulva." Amer. Tour. Med. Sci., 1915, vol. cxlix, p. 535. 
Cary, W. H. : " The Conservative Treatment of Gonorrhoea in Women." Am. Jour. Surg., 

191 1, vol. xxv, p. 373. 
Collyer, H. L. : " Fibroma of Labium." Amer. Jour. Obst, 1889, vol. xxii, p. 1252. 
Curtis, A. H. : " On the Pathology and Treatment of Chronic Leucorrhcea." Surg., Gyn. 

and Obst., 1914, vol. xix, p. 25. 
Demme: " Beitrag zur Tuberculose des Kindesalters." Wien, Med. Blat., 1887, Bd. 1. 
Dudley, E. C. : The Principles and Practice of Gynecology. Lea and Febiger, Phila., 1913. 
Edgar, J. C. : Obstetrics. P. Blakiston's Sons & Co. 
Fisichella, V. : " La cura dell' Ulcera cronica Vulvare." II Policlinico, 1915, vol. xxii, 

P- 485. 

Fromme: " Gutartige Geschwulste in das grossere Labien." Monats. f. Geb. u. Gyn., 1904, 
Bd. xx, S. 961. 

Gunther : " Esthiom / ene." Amer. Jour. Obst., 1904, vol. xlix, 373. 

Hamilton, Wallace : " Gonococcus Vulvovaginitis in Children." J. Am. Med. Assn., 
1910, vol. liv, p. 1 196. 

IJart: "Epithelioma Vulvae." London Practitioner, Feb., 1895, vol. liv, p. 118. 

Hensius, F. : " Vaccine Behandlung der weiblichen Gonorrhoe." Monatschr. f. Geburtsh 
u. Gynak., 191 1, vol. xxxiii, p. 426. 

Hurdon : " Pathology of the Reproductive Organs." Kelly-Noble's Gynecology and Abdom- 
inal Surgery, Saunders, Phila., 1907. 

Kimball: "Gonorrhoea in Infants, with a Report of Eight Cases of Pyaemia." Med. 
Records, N. Y., vol. lxiv, p. 761. 

Morrow, L., and Bridgman, O. : " Gonorrhoea in Girls ; Treatment of 300 Cases." J. A. M. A., 
May 25, 1912, vol. lviii, p. 1564. 

Munk, H. : " Ein Beitrage zur Kenntniss und Behandlung des Pruritus Vulvae." Prag. 
med. Wochenschr., 1902, No. 45. 

Norris : " The Diagnosis and Treatment of Gonococcal Vulvovaginitis in Infants and 
Young Children." J. A. M. A., 1915, vol. lxv, p. 327. 

Pichevin : " Esthiom'ene de la Vulve." La Sem. Gyn., 1905, T. x, p. 38. 

Powers, D., and Murphy, J. K. : "A System of Syphilis." Oxford Medical Publications, 
1908. 

Ravogli, A.: A Text-book of Gynecology. C. A. L. Reed, 1901. 

Sanger : " Aetiologie u. Behand. der Vulvitis Pruriginosa." Cent, f . Gynak., 1894, S. 154. 

Sinclair, J. F. : Investigations in Vulvovaginitis by Means of Female Urethroscope." 
Arch. Ped., 1914, vol. xxxi, p. 29. 

Stein, A. : " Primary Carcinoma of the Vulva." Amer. Jour. Obst., 1896, vol. lxxiv, p. 577. 

Taussig, F. J. : " The Prevention and Treatment of Vulvovaginitis in Children." Am. Jour. 
Med. Sci., 1914, vol. cxlviii, p. 480; Ibid. : " Etiologic Study of Vulvar Carcinoma." 
Amer. Jour. Obst., 1917. vol. lxxvi, p. 794; Ibid.: "Etiologic Study of Vulvar Carci- 
noma." Trans. Amer. Gyn. Soc, 1917, vol. xlii, p. 463. 



DISEASES OF THE EXTERNAL GENITALIA 191 

Taylor : " Venereal and Skm Diseases." Clinical Atlas, Lea and Febiger, Phila., 1889. 

Ibid. : Genitourinary and Venereal Diseases. Lea and Febiger, Phila., 1904. 
Wagner: " Zur Behandlung der Cervical Gonorrhoe." Berlin, klin. Woch., Dec. 25, 191 1, 

No. 52, p. 2339. 
Webster: "Nerve Endings in Labia Minora and Clitoris; Pathology of Puritus Vulvae." 

Edinburgh Med. Jour., July, 1891. 
Weinstein, E. : " Die Vaccinetherapie nach Wright bei der Vulvo Vaginitis der Kinder." 

Miinchen. med. Wochnschr., igio, vol. lvii, p. 762. 
White and Martin : Genito-Urinary Surgery and Venereal Diseases. By Martin, E., 

Thomas, B. A., Moorhead, S. W. J. B. Lippincott Company, Phila. and London, 1917. 



CHAPTER XII 
DISEASES OF THE HYMEN AND VAGINA 

Abnormal rigidity or abnormal elasticity cf the hymen may occasionally 
be found. The former may render intercourse impossible ; the latter may 
be compatible with coitus and miscarriage without injury. 

Cystic tumors of the hymen are at times observed. These are either 
congenital or have their beginning in the coalescence of the hymeneal folds 
following inflammation. 

Vaginitis. — Vaginitis is usually subacute or chronic, except in the case 
of children and elderly women. In the young and in the old the mucosa 
of the vagina and vulva is delicate and tender, so that it is more sus- 
ceptible to acute inflammatory lesions. When vaginitis occurs during 
the reproductive period, it is less likely to be acute, and depends 
upon repeated infection plus a mechanical irritation or injury, or upon 
some general condition that lowers the vitality of the vaginal mucosa. 
The predisposing factors of vaginitis are venous stasis, the hypersemia 
incident to pregnancy, small abrasions of the mucosa, and the irritation 
of foreign bodies. In infants and in young children gonorrhoea is the most 
frequent cause. A long-continued discharge of gonorrhoeal pus from the 
cervix is the most common cause in adults. Vesicovaginal fistula is almost 
always accompanied by vaginitis, and puerperal infections of different varie- 
ties may attack the vagina. Vaginitis may also complicate pneumonia, 
scarlet fever, diphtheria, typhus fever, dysentery, and measles, especially 
in children. 

In acute vaginitis the vaginal walls are red, swollen, hot, tender, and cov- 
ered with a mucopurulent or purulent discharge. As a rule, the entire 
length of the vaginal canal is not involved, except in children. The vulva 
is bathed in the discharge, which becomes highly offensive. 

In subacute or in chronic vaginitis the vaginal surface is covered with 
numerous small red spots, caused by inflammatory infiltration of the papillae 
in the mucosa. The overlying epithelium subsequently desquamates, and 
small eroded areas are formed. In old and in young persons such areas, 
when they are apposed, may become adherent. In this variety the vaginal 
walls are covered with a thinner and less purulent discharge than in the 
acute form. In old, chronic cases the lesions may be limited to eroded 
patches in the vaginal vault. In children the local examination should be 
confined to an inspection of the vaginal orifice or to the introduction of a 
small Kelly cystoscope into the vagina. In the adult, examination of the 
vagina is preferably made by means of a Sims' speculum, with the patient in 
the Sims' or in the knee-chest position. 

The treatment of acute vaginitis consists of rest in bed, the administra- 
tion of saline laxatives, and the use of warm vaginal douches of solutions of 
sodium chloride, sodium bicarbonate, or borax (i dram to I pint. If the 
192 



DISEASES OF THE HYMEN AND VAGINA 193 

pain is very severe, these douches must be given with great gentleness, 
using a soft-rubber catheter instead of a douche nozzle. The vaginal dis- 
charge must be caught upon vulvar pads, which should be burned. 

If the attack is gonorrhoeal in origin, the patient should be warned of the 
danger of carrying the infection to the eyes. 

After the acute stage has passed, the vaginal walls should be cleansed 
with absorbent cotton and painted with a 5 to 10 per cent, solution of silver 
nitrate. Following this a tampon covered with zinc oxide ointment should 
be inserted and left in place twenty-four hours. This treatment should be 
repeated at weekly intervals. In addition a daily douche of salt or borax 
solution (5i— Oi) should be ordered, to be followed by an astringent and 
antiseptic douche, such as the following: 

I£. Ac. boric , o iv 

Phenol. 

Pulv. alum, ex , aa 3 iv 

Ol. gaultheria? . ., mx xxx 

Ol. menth. pip mx xv 

Sig. — 1 dram to 2 pints of water ; used as a douche. 

Applications of silver nitrate (10 per cent.), followed by zinc oxide oint- 
ment, are especially effectual in cases of so-called senile vaginitis, occurring 
in women past the menopause. In this condition there is a thin, acid, offen- 
sive discharge, with irritation and redness of the vulvar mucosa, intense 
itching, and burning. Two or three applications of the silver nitrate and 
zinc oxide ointment to the entire vagina and vulva are usually sufficient to 
clear up the condition for a month or six weeks, when it may be necessary to 
repeat the treatment. Block and Llewellyn, also Brindeau, have had grati- 
fying' results from the use of the Bulgarian lactic acid bacillus (see page 198). 

The yeast treatment, as devised by Landau, consists of the introduc- 
tion, within the vagina, of a quantity of yeast fungi under conditions that 
favor their rapid growth and the destruction of all other bacterial forms. 
Landau used brewers' yeast and a solution of cane-sugar. 

A more convenient method consists of applying to the vagina, after thor- 
ough preparatory cleansing, two or three tampons moistened with a 10 per 
cent, solution of glucose and filled with dry yeast powder. The tampons 
are left in place for twenty-four hours, when they are removed and 
a douche of sterile water administered. The treatment is repeated at inter- 
vals of forty-eight hours. 

Curtis recommends particularly the use of antiseptic powders. Some 
that have given the best results are as follows : 

I£. Alumin. acetat 1 part 

Kaolin. 

Talc of each 2 parts 

Ifc. Pulv. alum ex. 
Ac. boric. 
Bismuth, subnitrat. aa. 

I£. Ac. tannic. 
Lycopod. aa. 

Paravaginitis. — (See Cellulitis.) 
13 



194 



GYNECOLOGY 



Vaginismus is the name given to hypersesthetic conditions of the vulva 
and vagina in which intercourse is rendered impossible because of painful 
contractions of the muscles of the vaginal outlet and perineum. The vaginal 
introitus may be too small or the hymen may be rigid, or the condition may 
be caused by some painful affection of the vulva (vulvitis, urethral caruncle), 
vagina (vaginitis), or pelvis (prolapsed ovary), or it may be neurotic in 

origin. In the first class 
of cases the treatment is 
obvious — viz., the removal 
of the cause. In the sec- 
ond class of cases gentle 
but persistent, gradual 
dilatation, supplemented 
by nerve sedatives and hy- 
gienic and tonic treatment, 
will effect a cure. In ob- 
stinate cases forcible dila- 
tation under ether or 
actual incision with plas- 
tic repair, so designed as 
to increase the caliber of 
the vaginal introitus or 
the vaginal canal itself, 
may be successful. The 
use of soothing ointments 
or washes, and the plan of 
gradually accustoming the 
patient to the presence of 
a foreign body are of value. 
The general health should 
be improved by suitable 
tonic or roborant treatment. 
Vaginal Cysts. — Vag- 
inal cysts, while the most 
frequent of the vaginal 
tumors, are nevertheless 
rare. They result from 
the distention of aberrant 
vaginal glands, inclusions 
of epithelium following 
operations, hsematomata, 
dilatation of lymph-vessels, and the echinococcus. Rarely dermoid cysts 
are found. Cysts may also have their origin in rests of the Wolffian duct 
in the upper part of the vaginal vault. Such cysts are often multiple, and 
occur in rows. Vaginal cysts are hemispherical or ovoid in shape, and pro- 
ject more or less into the vagina (Fig. 187). Occasionally they may be 
pedunculated. The overlying mucosa is thinned out. The contents of a cyst 
may be clear, thin, and watery, glairy and opalescent, or chocolate colored. 




> 



FlG. 1-87. — Cyst "of the posterior vaginal wall. 



DISEASES OF THE HYMEN AND VAGINA 



195 



When the tumor is small, symptoms may be absent. When the growth is 
large, there is interference with urination and defecation. The tumor may 
form an obstruction to intercourse or to labor. If the passage of the men- 
strual fluid is obstructed and an accumulation occurs above the tumor, a 
fetid leucorrhoea may be present. The condition must be distinguished from 
cystocele, rectocele, and suburethral abscess. 

The only treatment to be considered is excision. This is readily accom- 
plished by making an incision oyer the prominence of the tumor, in the 




Fig. i 88. — Sarcoma of vagina in a child 2V2 years old, showing the grapelike polypoid 

masses in the vaginal canal. (Kelly and Xoble's Gynecology and Abdominal Surgery. 

W. B. Saunders Co.) 



axis of the vagina, and shelling out the cyst wall from the surrounding 
tissues. The wound is then closed by buried and superficial sutures. The 
approach to a cyst in the upper part of the vagina may present some diffi- 
culty, and the difficulty of excision is always increased if the cyst ruptures 
before it is enucleated. When enucleation is impracticable, as much of the 
cyst wall as possible should be excised with scissors, and the remainder 
cauterized and packed. 

Fibromyoma of the vagina is an infrequent form of tumor. It presents the 
same peculiarities as fibromyoma elsewhere in the body. The treatment 
consists of enucleation followed by plastic repair. 



196 



GYNECOLOGY 



Sarcoma of the vagina is very rare. In adults it appears as a diffuse 
growth that may be situated in any part of the vaginal canal. In young 
children it is polypoid or grape-like in form (Fig. 188), and springs from the 
anterior vaginal wall. The only hope for cure of sarcoma of the vagina lies 
in early radical operation. Grape-like sarcoma of the vagina in children is 




FIG. 189. — A case of adenocarcinoma of posterior vaginal wall. (Kelly's 
Operative Gynecology. D. Appleton & Co.) 



practically hopeless, all but one of the reported cases having proved fatal, 
in spite of the fact that extensive radical operations had been performed. 
Carcinoma of the Vagina. — Primary cancer of the vagina is very rare; 
it is usually secondary to a growth situated higher in the genital tract (Fig. 
189). The treatment of carcinoma of t- e vagina is unsatisfactory, since the 
primary tumor is almost invariably beyond the pale of radical cure. In the 
majority of cases about all that can be done is to perform thorough curette- 



DISEASES OF THE HYMEN AND VAGINA 197 

ment and cauterization, and to apply the other measures advised for in- 
operable carcinoma. The remarkable results that have been achieved in 
recent years by the use of radium make this form of treatment a distinct and 
hopeful addition to the therapy of carcinoma of the vagina. 

Chorio-epithelioma of the vagina is a rare condition. It is caused by the 
deportation of chorionic villi from their original site in the uterus or tube to 
the vaginal blood-spaces and their subsequent growth and development 
in the new location. The appearance of the growth is suggestive of a 
vaginal varix. The treatment consists of prompt excision, together with 
removal of the primary seat of the growth. As in carcinoma of the 
vagina, radium constitutes the most hopeful form of treatment of 
chorio-epithelioma. 

Foreign Bodies in the Vagina. — Foreign bodies of all sorts have been 
found in the vagina. They may have been introduced by patients mentally 
deranged or have been left by accident or neglect of the patient, physician, 
or nurse. Among those most commonly found are broken glass douche nozzles, 
pessaries,, tampons, etc. Pessaries are not infrequently forgotten and while 
they give no inconvenience for a time, they gradually produce inflammation 
and ulceration. In elderly women the bloody, foul discharge may lead to 
a mistaken diagnosis of carcinoma. The symptoms usually subside on 
removal of the pessary, but considerable contraction and stenosis of the 
vagina may follow as a consequence. Not infrequently the pessary becomes 
practically embedded in the tissues and can be removed only piecemeal. 
In neglected cases of long standing, vesicovaginal or rectovaginal fistulas 
may result. 

Leucorrhcea. — Leucorrhcea (white discharge), in the common acceptance 
of the term, is the name given to a discharge from the genitalia that occurs 
independently of the menses. A leucorrhceal discharge is usually of a milky 
white color, but it may be yellow or tinged with blood ; it may be compara- 
tively odorless or very offensive. (See also Chapter VI, p. 99.) 

The treatment of a given case of leucorrhcea depends, of course, upon the 
underlying cause, which may be any lesion or group of lesions of the 
genital tract. 

Any case in which leucorrhcea is a prominent feature may require careful 
study, for there is hardly any symptom that causes greater discomfort and 
distress. The most troublesome cases are those in which the recognizable 
lesions are not marked. In fact, there may be no manifestations beyond 
the constant presence, on examination, of more or less discharge in the 
vaginal vault and about the external genitalia. 

If all possible sources of the disorder have been sought for and no 
cause can be found, or if the presumptive underlying condition has been 
corrected and no improvement results, the indications point to an abnormal 
vaginal flora as the causative factor. 

Curtis, who has studied these persistent cases, found that in a ma- 
jority anaerobic bacteria were present in the cervix, vagina, and vulva. 
The ordinary pathogenic organisms were rarely found. The gonococcus 
was not often present, but this investigator concluded that a gonococcus 



198 GYNECOLOGY 

infection was frequently the precursor of the persistent and less virulent 
infection. The uterine cavity remains uninvolved. 

An examination of smears of the discharge shows, besides many bacteria, 
pus cells and epithelium in varying proportion. Not infrequently a dis- 
charge that resembles pure pus is made up almost entirely of mucus and 
desquamated epithelium. 

In these cases the aim is to destroy the lower grade anaerobic organisms 
and then restore the normal bacterial flora. This is done, first, by employ- 
ing disinfecting applications, tampons, or douches, and then by placing a 
culture of the bacillus Bulgaricus (lactic acid bacillus) in the vaginal vault. 
As a means of disinfection a thorough application to the cervical canal and 
entire vagina of silver nitrate, 10 per cent., is perhaps the most effectual of 
the older remedies, but the tincture of iodine may be equally efficient. Re- 
cently a solution of chlorazine, followed by dichloramine-T tampons (2 per 
cent, in eucalyptus oil) has given excellent results. Findley recommends 
packing the vagina daily for a week with Fuller's earth, placing as much 
as possible into the vagina at every sitting without removing that 
previously introduced. 

After the anaerobic bacteria have been destroyed or their number deci- 
mated by this plan, then cultures of the Bulgarian lactic-acid bacillus x mixed 
with sugar may be introduced. For this purpose tablets of the lactic-acid 
bacillus are most convenient; they should be moistened and mixed into a 
thick paste with sugar and a little water; this is spread upon the vaginal 
walls in the fornices. The treatment should be repeated every other day for 

1 " Tcchnic. — The patient is placed in the usual dorsal gynecologic position, and a thor- 
ough pelvic examination made, including smears, when indicated. A bivalve speculum is 
then inserted into the vagina, and the cervix and the upper vaginal canal exposed. The re- 
action of the vagina is then taken by moistening a piece of litmus paper in the vaginal 
secretion, after which the vagina is thoroughly cleansed of mucus and leucorrhceal dis- 
charges by means of a simple alkaline spray, and the vagina is then dried with cotton 
pledgets. A lactic acid tablet, preferably one that is readily soluble and made with a 
lactose base, is placed in a medicine glass and moistened with one or two drops of sterile 
water dropped on the tablet by means of a small pipette or eye-dropper. It is important not 
to supply more than a few drops of water to the tablet, otherwise the tablet will completely 
disintegrate and cannot be readily handled. 

" If the proper kind of tablet is used, and only enough water is applied to moisten 
it will attain the consistency of thick cottage cheese, and may be readily lifted in toto by 
a pair of forceps. It is then placed in the upper vaginal canal, and spread over the walls 
and on the cervix by means of the forceps. If the tablet is of the proper consistency, it 
will adhere to the vaginal mucosa wherever placed, and will show no tendency to run out 
of the vagina, as is the case with ordinary solutions. The speculum is next withdrawn 
half way, with its blades open, to allow the upper vaginal canal to close over the tablet that 
has been applied. Finally the blades are closed and the instrument is withdrawn. No 
tampons are applied. The patient is instructed to return in a week, and all douching is 
absolutely interdicted. On her return the same technic is repeated, and she returns once 
a week for a reimplantation of the bacilli, until the vagina is acid — a, result which, in a 
favorable case, is attained in about three or four weeks. After the reaction has become 
acid, no treatment is given so long as it remains so, although the patient returns at gradu- 
ally increasing intervals to have the reaction taken. In favorable cases it is usually found 
necessary to reimplant organisms at intervals of from three to four weeks,- since after that 
time the organisms seem to die, or at any rate to lose their potency. We might, therefore, 
state here that the treatment is seldom a permanent cure, but rather a good palliative 
measure, requiring attention about once a month and superseding douches." — (Block and 
Llewellyn : J. A. M. A., vol. lxix, No. 24, p. 2025, Dec. 15, 1917.) 



DISEASES OF THE HYMEN AND VAGINA 199 

a week, and in the interim no vaginal douches or tub-baths should be taken. 
Even in successful cases the implantation may need to be repeated occasionally. 

Working on the theory that bacteria cannot thrive in the absence of 
moisture, Nassauer recommends insufflation of the vagina with fine white 
clay powder (bolus alba). For this purpose he has devised an apparatus 
that distends the vagina while the insufflation is being made. (The same 
effect may be secured by packing the vagina with the powder while the 
patient is in the knee-chest position.) The treatment should be carried out 
at first three or four times a day, but later less frequently. Nassauer asserts 
that a cure was effected in the majority of instances in 300 cases in which 
this treatment was used. 

As a result of careful and scientific study of a large series of cases 
Curtis found that the most successful plan of treatment consisted in the use 
of autogenous vaccines, combined with dry cleansing of the vagina and 
applications of powder. This should be preceded by the destruction, by 
means of the cautery or otherwise, of cervical glands that are producing 
an excessive mucous discharge. Care of the general health, the use of 
active emunctories, and the treatment of associated pelvic lesions are all 
adjuncts not to be disregarded. 

BIBLIOGRAPHY 

Abrams, O. : " Neuere Versuche Uber die Hefebenhandlung des weiblichen Fluors." 

Monats. f. Geburtsh. u. Gynak.. 1910, vol. xxxi, p, 89. 
Block, F. B., and Lewellyn, Thos. H. : " The Treatment of Leucorrhcea with Lactic Acid 

Bacilli." Jour. Amer. Med. Assoc, vol. lxix. Xo. 24, Dec. 15, 1917. 
Brindeau, L. : " Les Cultures de Bacillus Lactiques dans Le Traitement de Tlnfection 

Puerperale." Arch. mens, d'obst. e. d. gynec, 1912, i, 225. 
Cullen, T. S. : " Vaginal Cysts." Trans. Amer. Gyn. Soc, 1904, vol. xxix, p. 459. 
Curtis, A. H. : " The the Pathology and Treatment of Chronic Leucorrhcea." Surg., Gyn. 

and Obst., 1914, vol. xix, p. 25; Ibid. : "On the Etiology and Bacteriology of Leucor- 
rhcea." Surg., Gyn. and Obst., 1914, vol. xviii, p. 299. 
Holt : " Gonococcus Infections in Children, with Especial Reference to the Prevalence 

in Institutions and Means of Prevention." X. Y. Medical Jour, and Phila. Med. Jour., 

March, 1905, vol. lxxxi, Xos. 11 and 12. 
Hunner, G. L. : " The Treatment of Leucorrhcea with the Actual Cautery." J. A. M. A., 

1906, Xo. 3, vol. xlvi. 
McFarlaxd, J.: "Sarcoma of the Vagina." Am. Jour. Med. Sci., 1911, vol. cxli, p. 570. 

(Complete Literature.) 
Nassauer, M. : " Sur le Traitement des ficoulements chez da Femme." Annales de Gyn. et 

d'Obst., 191 1, vol. viii, 2 serie, p. 477. 
Taussig, F. J. : " The Prevention and Treatment of Vulvovaginitis in Children," Amer. 

Jour. Med. Sci., 1914, vol. cxlviii, p. 480. 



CHAPTER XIII 
INJURIES TO THE PERINEUM AND THEIR RESULTS 

Mechanics of Normal Support. — The anatomy of the perineum, the 
origin and insertion of the various muscles that make up the pelvic dia- 
phragm, and the arrangement of the pelvic fascia have been described. It 
only remains to state that the supporting power of the perineal floor does 
not depend exclusively upon the muscle or the fascia. For the greater part 
of the time one reinforces the other ; thus when the perineal diaphragm is in 
absolute repose, the fascia maintains its form ; during urination, defecation, 
labor, and on physical exertion the muscular tissues are chiefly called upon 
to functionate. 

The levator ani and the pelvic fascia support the rectum, and in doing so 
the posterior vaginal wall, which is closely connected with the anterior wall 
of the rectum, is also supported. The vaginal walls being in contact, the 
support of the anterior wall is partly dependent upon the posterior wall, 
and the base of the bladder is in turn supported by it. Needless to say, the 
constrictor vaginae, the transversus perinsei, the triangular ligaments, and 
the endopelvic reflection of the pelvic fascia play an important part in the 
support of these structures, and when the muscles of the pelvic floor are in 
repose, the vagina, bladder, and rectum are maintained in their normal 
position largely by means of their fascial attachments. 

While the contraction of the levator ani muscle elevates the rectum, the 
external sphincter, in addition to constricting the anus, has a tendency, by 
virtue of its attachment to the tip of the coccyx, to draw the anus back- 
ward. When both the levator ani and the external sphincter act in unison, 
a certain amount of antagonistic action takes place at the site of the anus, 
which has been compared by Kelly to a " cut-off " valve. 

The vagina and the urethra pass through both the anterior and the pos- 
terior layers of the triangular ligament. The base of the bladder is sup- 
ported by the anterior vaginal wall, a few small muscular slips, the triangu- 
lar ligament, and the pubo-vesico-cervical reflections of the pelvic fascia. 
The bladder is also attached lightly to the posterior surface of the symphysis 
and to the cervix. The intrinsic fascial and muscular supports of the blad- 
der are sufficient to maintain it in position so long as they are fortified by 
the supporting action of the levator ani (Fig. 192). Just as soon as this 
supporting action is removed, however, they become incapable of holding the 
bladder permanently in its proper position. 

Forms of Injury, Immediate and Remote. — A study of the mechanics 
of labor shows that, during the second stage, as the head advances 
through the parturient canal, lacerations of the vagina and perineum may 
occur in one of two ways — the advancing head may strip the vag- 
inal wall loose from its underlying attachments and push it bodily in 
front of it, or the muscular loops and fascia that surround the parturient 
canal and the vaginal outlet may be so greatly overstretched as to be 
completely severed, the tear either passing through the mucous membrane 
200 



INJURIES TO THE PERINEUM AND THEIR RESULTS 201 

to the surface or being entirely submucous and not communicating with 
the exterior. Either form of tear may take place in the vaginal sulci or in the 
median line. When it occurs in the median line, it may involve the perineal 
body alone, or it may pass directly through the perineal body and the 
external sphincter into the rectum. Simultaneously the anterior vaginal 
wall, at the introitus, may undergo various forms of trauma, but the deepest 
and most pronounced lacerations are usually found posteriorly. A median 
laceration through the perineal body, since it does not involve the levator 
muscles and fascia, affects the perineal diaphragm but slightly. It does 
destroy in part the supporting action of the transversus perinaei muscles, the 
constrictor vaginae, and the triangular ligaments. Nevertheless, if the levator 
ani itself is intact, there is no great impairment of the pelvic diaphragm. 




Fig. 190. — Large rectocele in a multipara. 

A sulcus tear (Fig. 193) means a separation or an avulsion of the an- 
terior fibers of the levator sling and a tear of the levator fascia, with a 
consequent loss of support to the rectum to which these fibers are attached. 
If one sulcus is lacerated, the other is, as a rule, affected also, although it 
may be to a lesser degree. Consequently the lower part of the rectum 
loses its support, and this affects the corresponding part of the vagina and 
the bladder. 

9 When such a laceration has occurred, the action of the external sphincter 
in drawing the anus backward becomes a factor of considerable importance 
in the subsequent course of anatomic changes. Being deprived of its natural 
support, the lower end of the rectum is drawn backward with each contrac- 
tion of the sphincter, and the column of faeces, instead of being driven toward 



202 



GYNECOLOGY 



the anus during defecation, is driven toward the vagina, the posterior wall 
of which tends to pouch, forming a rectocele (Figs. 190 and 193). 

When the anterior vaginal wall and the base of the bladder are deprived 
of the support that is normally afforded by an intact levator muscle and 
fascia, there is a tendency for the parts to sag, and their support now 
depends entirely upon their intrinsic fascial attachments and a few small 
muscles. When, in addition to levator incompetence, injuries have been in- 
flicted on the fascia of the anterior vaginal wall and the vesical base, asso- 
ciated, perhaps, with a separation of the anterior vaginal wall from its 







Fig. 191. — Sulcus tears and thinning of perineal body in a multipara. 

underlying tissue, a sagging of the base of the bladder during attempts at 
lifting or urination occurs, with the subsequent formation of a cystocele. 

The chief effect of a median tear that passes not only through the perineal 
body but also through the external sphincter muscle into the rectum, complete 
tear, consists in an inability to control the passage of flatus or of faeces from the 
bowel. The tear rarely may be entirely submucous, the rupture in the 
fibers of the external sphincter being unaccompanied by any lesion in the 
overlying skin or mucous membrane. After a difficult labor incontinence of 
gas or of faeces may be due to a temporary paralysis of the sphincter muscle, 



INJURIES TO THE PERINEUM AND THEIR RESULTS 203 

the result of the pressure and the stretching to which it has been subjected. 
This temporary incontinence may simulate a submucous rupture of 
the sphincter. 

A complete tear, if uncomplicated, especially if it occurs directly in the 
median line, affects the support of the perineum but little (Fig. 194). The 
levator fibers are not greatly affected, and it is quite unusual, although, of 
course, it is possible, for a patient who suffers with a complete tear of the 
perineum to display many symptoms of general relaxation of the pelvic floor. 
In some cases this is probably due to the fact that the great distress caused 
by a complete tear usually leads to comparatively early operative treatment. 




■cicXococtvjgeu.? 



VtMoXw ota X3\vvoLugu.\a.'c \\$ 



Fig. 192. — Schematic drawing to show the support 
given by the levator ani and triangular ligaments 
to the pelvic viscera; note the pull upward by these 
structures to counteract the downward intra-ab- 
dominal pressure. The rectum, anus and perineal 
body are well held up. 



Fig. 193. — Schematic drawing to show the effect of 
sulcus lacerations of the levator ani and triangular 
ligament; the rectum, anus and perineal body drop 
back, having lost their support, the recto-coccygeus 
slip of the external sphincter pulls the anus and the 
lower end of the rectum backward, the fecal current 
is directed toward the gaping vaginal orifice and the 
posterior vaginal wall; nothing now opposes the 
downward intra-abdominal pressure but the uter- 
ine ligaments and the intrinsic attachments of the 
bladder. 



Symptoms. — The symptoms of a relaxation of the perineum are attribut- 
able to a loss of the support that it normally affords to the generative tract, 
and to the secondary lesions which it may occasion, namely, cystocele, recto- 
cele, and descensus uteri (Fig. 195). The symptoms do not manifest them- 
selves until the patient has left her bed and has resumed her daily duties. 
There is a feeling as if the entrance to the vagina was open, and as if the 
supporting nower of the pelvic floor was lost. This feeling of weakness be- 
comes more marked when any unusual muscular effort is attempted. If the 
exertion is continued for any length of time, standing or walking, the patient 
complains of sacral backache, a dragging sensation in the lower abdomen, 
and a feeling as if the vaginal structures were about to protrude. The 
symptoms are all relieved on assuming the recumbent posture. 



204 



GYNECOLOGY 



If a well-marked rectocele (Fig. 190) develops there will be difficulty in 
defecation, associated with a peculiar pain that is caused by impingement of 
the fecal column upon the posterior vaginal wall. At times the attempt 
at defecation is successful only after the patient has taken an enema to 
liquefy the faeces, or she may learn that by pressing upon the posterior vaginal 
walls with the fingers she can deflect the fecal column through the anus. 

When a cystocele (Fig. 196) develops, the patient complains of an in- 




Fig. 194. — Complete laceration of perineum. Xote the sphincter pits and the nearly 
straight line of the divided muscle. 



creased desire to urinate, especially when she has been upon her feet any 
length of time, and urination may be accompanied by a burning sensation or 
pain. In w r ell-marked cystoceles the bladder becomes sacculated, and the 
patient is unable to empty the organ completely, so that there is always 
present a certain amount of residual urine which may undergo amm6niacal 
change and give rise to a low-grade cystitis. Occasionally the patient dis- 
covers that she is able to empty her bladder by pressing the cystocele up- 
ward with the fingers. 

Diagnosis.— All the symptoms of relaxation of the pelvic floor are improved 
by the recumbent posture or by vaginal tampons and the application of a snug 
perineal bandage. In most cases, on examination the relaxation will be 



INJURIES TO THE PERINEUM AND THEIR RESULTS 205 

revealed by simple inspection, but occasionally a few associated symptoms may 
be especially brought out by palpation. In the normal individual the 
vaginal introitus is closed ; the perineal body is thick, and its surface is 
slightly concave ; the anus is well puckered and drawn up close to a line 
connecting the tuberosity of the ischia ; the natal and the gluteal clefts are 
deep. If the patient is directed to bear down, there will be a bulging of the 



^' 







Fig. 195- — Prolapse of uterus with cervix projecting from vulva; prolapsed rectal mucosa; fibrolipoma 

of thigh. 

perineum (Fig. 197), but no opening of the vagina and no prolapse of 
its walls. 

The relaxed perineum presents quite a different appearance from that 
just described. The vaginal introitus is open; the anterior and the posterior 
vaginal walls are not in contact ; the perineal body is attenuated and bulging; 
the anus is retracted, the pucker of the sphincter muscle is less marked, and 
the natal and the gluteal clefts are shallow. If the woman is directed to bear 
down, the anterior and posterior walls of the vagina tend to descend, and if 
cystocele or rectocele is present, the characteristic protrusion will be noticed 
(Fig. 198). The perineal reflex is weak or absent. 



206 GYNECOLOGY 

When the perineal diaphragm is intact, a finger inserted within the 
vagina perceives, at either side, the anterior border of the levator ani muscle 
and the substantial thickness of the perineal body. In the relaxed perineum the 
perineal body may be extremely thin, so that there is almost no fascia or 
muscle between the s.^n surface and the anterior rectal wall. If the 
levator muscle has been torn, a break in its anterior border may be felt, and 
the separation of its fibers may have left a distinct furrow or cleft in the 
vaginal sulcus into which the finger may be laid. In marked rectoceles the 



Fig. 196. — Cystocele: Rectocele; note the gaping vaginal orifice; 
the anterior and posterior walls are not in contact; the perineal body- 
is thin and dropped down; the perineal raphe is obliterated. 

posterior vaginal and the anterior rectal wall is readily everted through the 
anus, or slight pressure upon the posterior wall of the vagina with a finger in 
either sulcus may be sufficient to expose the cervix. If the woman is 
placed in the Sims' or the knee-chest posture, marked ballooning of the 
vaginal vault at once occurs. Retraction of the posterior vaginal wall with 
a speculum is unnecessary. The presence of a rectocele can readily be dem- 
onstrated by rectal examination : when the finger is directed forward into 
the anterior rectal pouch, it can carry the posterior vaginal wall before it, 
almost without any resistance, through the vaginal orifice. The relations 



INJURIES TO THE PERINEUM AND THEIR RESULTS 207 

of a cystocele can be demonstrated with the aid of a catheter or a 
vesical sound. 

The symptoms and diagnosis of a complete perineal tear are dependent 
chiefly upon the observation of the patient that she has involuntary passages 
of faeces or flatus from the rectum. This lack of con. ol may not be absolute. 
Thus the woman may., under ordinary circumstances, be able to hold both faeces 
and gas, but when the intestinal contents is liquid, as following a laxa- 
tive or an enema, inhibition may be deficient or faulty. In such cases the 




Pig. 197. — Normal nulliparous outlet, patient straining. Fig. 198. — Relaxed outlet, patient straining. 

laceration may involve only the fibers of the external sphincter, leaving the 
internal sphincter intact, or fibrous union of the sphincter ends may have 
occurred and may be so nearly perfect that the muscle under usual condi- 
tions is competent. 

The objective symptoms of a complete tear consist chiefly in an altered 
appearance of the anus. This muscle, instead of being circular and puck- 
ered throughout its entire extent, is bow-shaped or straight, and more or 
less deficient anteriorly where the tear in the posterior wall of the vagina 
and the" recto-vaginal septum exposes the mucosa of the rectum, which pre- 
sents a bright-red color. The pucker of torn muscle ceases at a varying dis- 



208 



GYNECOLOGY 



tance to either side of the median line, depending upon the position and 
extent of the tear ; on both sides, directly over the point where the pucker- 
ing ends, there is a retraction or a dimpling of the skin surfaces. 

The median tear and the exposure of the rectal mucosa are the result of a 
laceration directly through the posterior vaginal wall, perineal body, and 
anterior wall of the rectum. The dimples on either side are known as the 
sphincter pits, and mark the position of the retracted ends of the 
divided sphincter. 




Fig. 199. — Relaxed outlet. 

Many variations of this typical picture may occur. The median tear 
may be insignificant, barely involving the external sphincter and not reach- 
ing the rectovaginal septum, or the tear in the sphincter may be almost 
completely submucous ; in the latter event no external injury is apparent, 
but the sphincter ends are retracted, and upon inserting the finger into the 
rectum the failure of the muscle to surround the anus completely can readily 
be determined. 

Treatment. — Needless to say, it is the duty of the obstetrician to repair, 



INJURIES TO THE PERINEUM AND THEIR RESULTS 209 



H 



directly after labor, any small injuries of the perineum that are present. 
The question of operating at once when the labor has been prolonged 
or difficult ; when considerable bruising of the tissues has occurred and the 
chances of infection are multiplied, and when detachment of the vaginal 
walls and submucous injuries appear probable, is still a matter of doubt. 
It appears, however, that if the patient is subjected to operation a week or 
two after, rather than at the time of, delivery, she will ultimately be in 
better condition. 

Except in the case of very simple lacerations, swelling and cedema are so 
severe directly following labor that, in spite of the most painstaking care, 
an immediate perineorrhaphy is often disappointing in its result. At this 
time submucous injury may easily 

escape observation, and because of dis- ^ 

tortion the parts cannot be apposed 
perfectly. It is good practice in these 
cases, whenever possible, to obtain the 
patient's consent to postpone the opera- 
tion for about a week or ten days, when 
more satisfactory surgical measures 
may be undertaken, in submucous in- 
juries making a denudation and passing 
deep sutures. The more frequent use « 
of perineotomy, lateral or median, in 
the second stage of labor, with imme- 
diate primary repair, will obviate a ma- 
jority of extensive lacerations and pre- 
serve the integrity of the pelvic floor. 
This subject, however, belongs to the 
domain of obstetrics ; here we deal 
chiefly with the secondary operations 
of perineorrhaphy, which belong to the 

£ 1 j r i Eig. 20 °- — Emmet perineorrhaphy. Outline of the 

tieiQ OI gynecology. denudation, two vaginal and one perineal triangle. 




PERINEORRHAPHY 

Many operations have been devised for the restoration of the posterior 
segment of a relaxed pelvic floor, but two stand out preeminently : one is the 
operation of Emmet, and the other is the operation of Hegar. Although 
these remain as the two types of operation that are most efficient, excellent 
modifications of each have been devised. 

In all operations of this sort, two objects are to be achieved : the first is to 
take up the lax and redundant posterior vaginal wall, and the second is to 
bring together the lacerated borders of the levator muscle and fascia, as well 
as the retracted edges of the transversus perinaei and the constrictor vaginae 
muscles and the fasciae that meet in the median line and are interposed be- 
tween the vagina and the rectum or that surround the vaginal outlet. 

In the Emmet operation the denudations involve each lateral sulcus of 
the vagina; this operation is, therefore, particularly well adapted to those 
14 



210 



GYNECOLOGY 



cases of relaxation that are due to sulcus tears. The sulcus denudation not 
only gives access to the torn and retracted fibers of the levator sling, but also 
takes up the redundancy of the posterior vaginal wall and attaches it to the 
fixed structures and fascia in the neighborhood of the pubic rami. 

Hegar's operation is better adapted to those cases in which the tear is 
in the median line, and involves especially the perineal body; it is also the 
operation of choice in cases of relaxation of long standing, in which restora- 
tion of the pelvic floor must depend largely upon the fascial rather than 
upon the muscular supports. It is especially useful in the relaxation asso- 
ciated with the atrophy that takes place at the time of the menopause. 

Both operations bring together structures that may have been divided 
or separated in the median line, and unite between the anus and the vaginal 
orifice, the transversus perinsei, triangular ligaments, and the most anterior 
fibers of the levator ani. 





n 



Fig. 201. — Emmet perineorrhaphy. The denuda- 
tion completed. Sutures in one sulcus introduced 
but not tied. Note that the sutures are placed in 
such a manner that they will elevate the rectocele. 



Fig. 202. — Emmet perineorrhaphy. 
The sulcus sutures tied on both sides. 
Crown sutures introduced. Note that 
they are inserted and brought out in- 
side the denuded area. 



The Emmet Operation. — Three points are selected and fixed with ten- 
acula : First, the middle of the rectocele ; second and third, a point just 
below Bartholin's duct, at either side of the vaginal orifice. By making- 
traction on the central and on a lateral tenaculum, first on one side and then 
on the other, the borders of three triangular areas are brought into prom- 
inence and outlined by a scalpel, the incision being carried through the 
mucous membrane (Fig. 200). These incisions mark the areas where 
acnudation is to be done, and should be carried up sufficiently high in 
either sulcus to embrace the entire extent of the relaxation or of the tear. 
The denudation is made in strips, by means of tissue forceps and curved 
scissors, care being taken to remove the mucosa and skin uniformly and 
to leave no undenuded areas. In the young, child-bearing woman as much 



INJURIES TO THE PERINEUM AND THEIR RESULTS 211 



of the mucosa as possible should be preserved, the borders of the denuda- 
tion being undermined, if need be, to expose the muscles and fascia. 

The sulcus sutures are introduced, as shown in the illustration (Fig. 
201). They are passed in such a way as to attach the loose posterior vaginal 
wall to the fixed lateral part, and to reunite and reattach to the muscular 
coat of the rectum the divided fibers or fascia 
of the levator ani muscle. 

The sutures of the perineal triangle are 
known as the crown sutures (Fig. 202). 
They unite the structures that have been 
separated in the median line, restoring the 
perineal body and the muscles and fascia 
that meet normally at that point, and also 
draw some of the fibers of the levator ani 
muscles to the front, between the anus and 




the vagina, attaching them to the corre- 



FiG. 203. — Showing transverse fascial split 
and introduction of crown sutures. 



sponding fibers of the opposite side. 

The most approved method of performing this operation varies some- 
what from the classic description of Emmet. Care is taken to push the tip 
of the rectocele up into the vagina so as to avoid making traction upon the 
posterior vaginal wall, which would pull on the cervix and have a tendency 
to displace the uterus backward. As was previously pointed out, the 
sutures should be so passed that the posterior vaginal wall will be elevated 
instead of pulled down (Fig. 204). Before introducing the crown sutures, 
it is a good plan to divide the fascia of the denuded perineal triangle by a 
transverse incision from one side to the other (Fig. 203). This separates 
the structures to be united into two layers, each one of which is united in 
turn to its fellow of the opposite side by several extra-fine catgut sutures. 





Fig. 204. — Diagrammatic sketches of Emmet perineorrhaphy. 



The crown sutures are introduced in the ordinary way, surrounding both 
layers. By this plan a firmer union of the muscle and fascia which are 
brought together in the median line is obtained. 

Hegar's Operation. — As in the Emmet operation, three points are fixed 
by tenacula. the tenaculum catching the rectocele being placed at a higher 



212 



GYNECOLOGY 




INJURIES TO THE PERINEUM AND THEIR RESULTS 213 



point than in the Emmet operation ; indeed, in cases of marked relaxation 
the tenaculum is inserted nearly at the top of the vagina. Ordinarily, how- 
ever, the point of attachment is about an inch above where it would be for 
the Emmet operation. 

The area to be denuded is determined as follows: When traction is 
made on the three tenacula, a fold of the posterior vaginal wall will be lifted 
up in the median line; this fold 
is triangular in shape, with its 
sides slanting toward the vaginal 
sulcus on either side. The bor- 
ders of this fold are definitely 
established by drawing the rectal 
tenaculum upward and forward 
and the lateral ones to either side. 
The sides of this triangle are out- 
lined by an incision through the 
mucosa running along each bor- 
der to the corresponding vaginal 
sulcus. From the sulci the in- 
cision is carried upward and for- 
ward on either side to a point 
below the lateral tenaculum. A 
posterior incision is then made 
along the line of junction of the 
skin surface of the perineum with 
the posterior vaginal wall, be- 
tween the two lateral tenacula 
(Fig. 205). The area outlined in 
this way is then denuded in the 
manner described for the Emmet 
operation. 

The anterior wall of 
the rectum and the levator 
muscles and fascia are clearly 
exposed by blunt dissection. The adjacent borders of the posterior 
vaginal wall, the rectovaginal fascia, and the laterally lying fascia and 
fibers of the levator ani are now brought together by a series of interrupted 
sutures (Fig. 206). These sutures are continued in the median line to the base of 
the triangular denudation; as each succeeding suture is introduced, the pre- 
ceding one, which until that time has served as a point of retraction, is cut, 
and the tissue which it grasps is allowed to slip up into the vagina. These 
median sutures take up the redundancy of the posterior vaginal wall, fix 
the tissues to the underlying rectovaginal fascia, and pull up and reattach 
in the median line, the rectovaginal fascia, the rectal wall, the retracted 
levator ani fibers and the levator fascia. (See also Figs. 208, 209 and 210.) The 
perineal sutures or the crown sutures are introduced in much the same 
manner (Fig. 207) as in the Emmet operation, with a transverse split as 
described on page 211, and practically have the same effect, so that the 




Fig. 207. — Hegar perineorrhaphy. Crown sutures in- 
troduced. The drawing does not show the full out- 
ward sweep of the needle. The beginning of the 
subcuticular suture. 



214 



GYNECOLOGY 



chief difference between the two operations consists in the mode of dealing 

with the rectocele and with the torn and relaxed levator ani muscle and fascia. 

Operation for Complete Tear. — The essential points in the operation for 

a complete tear of the perineum are : (i) To restore the rectovaginal septum; 

and (2) to bring together 
the divided ends of the 
sphincter. Although, as 
has previously been stated, 
it is unusual to find a re- 
laxation of the levator ani 
fibers in connection with 
a complete tear, the de- 
nudation required for such 
an operation includes also 
the denudation made for 
either the Hegar or the 
Emmet operation (Figs. 
200 and 205 ) . This is done 
not so much for the pur- 
pose of catching the re- 
tracted ends of the levator 
muscles as it is for the pur- 
pose of restoring fully the 
perineal body and the 
rectovaginal septum. 

For this reason the last 
part of the denudation fol- 
lows either the Emmet or 
the Hegar type of opera- 
tion, although it is not at 
all extensive. The lower 
border of the line of denu- 
dation runs from the tenacula fastened below Bartholin's duct downward 
over the perineal body to the sphincter end on each side, which it encircles, 
and is then continued along the border between the rectal and vaginal 
mucosa to the median line, at the apex of the tear in the rectovaginal 
septum (Fig. 211). 

When the tissue immediately over the sphincter pits has been denuded, 
the ends of the muscle are sought for with tissue forceps and separated 
slightly from the surrounding cicatricial tissue, so that they can be well drawn 
up and thoroughly exposed. The extreme ends of the sphincter may be 
snipped off in order to secure a better surface for approximation. The 
denudation along the margin of the tear in the rectal wall should be very 
carefully performed, so as to afford as clean and as broad a line for approxi- 
mation as possible. 

The first sutures restore the rectovaginal septum ; they should consist of 
No. 1 chromic gut (ten-day), and be introduced from the perineal side, em- 
bracing the tissue down to but not penetrating the rectal mucosa (Fig. 212) ; or 




FlG. 208. — Hegar perineorrhaphy. Levator ani suture in marked cases 
— upper sutures. 



INJURIES TO THE PERINEUM AND THEIR RESULTS 215 

they should be of fine linen, introduced from the rectal mucosa and tied within 
the bowel (Fig. 213). The first suture should be passed through the very apex 
of the rectovaginal tear ; below this point they should be passed at intervals 
of one-eighth of an inch until the sphincter muscle is reached. 




Fig. 209. — Hegar perineorrhaphy. Levator Suture in marked cases. The upper sutures have been 
introduced. The introduction of the lower suture is indicated. The rectum is pushed back by the finger. 



The sphincter end on each side is now pulled directly into the wound, 
and two No. 1 ten-day chromic catgut sutures are introduced from side to 
side, each suture catching both sphincter ends (Fig. 212). A No. 1 ten-day 
chromic catgut suture is now passed from a point external to the sphincter end on 
one side, through the tissues external to the margin of the rectovaginal tear, 
carried around above the apex of the tear, continued through the tissues of 
the opposite side, and brought out at a point opposite the site of its intro- 
duction (Fig. 214, No. 3). This stitch takes the strain off the sutures that ap- 
proximate the sphincter ends. For the remainder of the operation the introduc- 
tion of sutures is identical with that described for either the Emmet or the Hegar 
type of operation, omitting the transverse split of the tissues at the outlet. 
The operation is completed by the introduction of subcuticular sutures of 
No. o chromic gut, as shown in Figs. 210 and 214. 



216 



GYNECOLOGY 



ANTERIOR COLPORRHAPHY; CYSTOPEXY 

The surgical treatment of relaxation or ptosis of the anterior vaginal 
wall and the base of the bladder (cystocele) depends upon the extent of the con- 
dition, and the structures involved ; this varies considerably in different cases. The 
anterior vaginal wall may be redundant and simulate a cystocele in appear- 
ance when in reality the lesion is nothing more than an overstretching of 

the vaginal mucosa and a separation of it 
from the underlying tissues. Or in con- 
nection with a stretching and a separation 
of the vaginal Avail there may be an actual 
rupture of the muscular and fascial sup- 
ports of the vesical trigone, an overstretch- 
ing or a tearing of the fascia that runs be- 
tween the bladder and the vagina from 
the cervix to the pubes (pubo-vesico-cer- 
vical fascia "bladder pillars"), or an ex- 
tensive separation of the normal attach- 
ment of the bladder to the cervix. 

While the simplest of these conditions 
requires nothing more than a resection of 
the redundant vaginal mucosa, the more 
complicated cases demand, in addition, a 
reduplication of the under surface of the 
bladder, a reuniting of the torn muscles 
and the fascia that support the bladder, 
and a reestablishment of the normal rela- 
tions of the bladder to the cervix. Many 
operations have been devised to meet 
these requirements. 

Cystocele Operations— Martin's Oper- 
ation. — Martin's operation is the simplest 
form of anterior colporrhaphy and cysto- 
pexy, and is applicable only to small cys- 
toceles. The operation consists of outlining 
an oval area upon the anterior vaginal wall, the longest diameter of the oval being 
in the median line. After removing the mucosa by means of tissue forceps 
and scissors, the adjacent areas on either side of the median line of the 
denuded oval are brought together by sutures introduced from side to 
side, through the vaginal wall. 

Sanger's Operation. — This type of operation is performed in all but the 
simplest cases, and was first elaborated by Sanger. By means of a tenaculum 
the anterior vaginal Avail is caught in two places — posteriorly, just in front 
of the cervix, and anteriorly, I cm. below the urinary meatus. The amount of 
redundancy of the anterior vaginal wall is determined by approximating, with 
tissue forceps, the vaginal tissues to either side of the median line, and then 
outlining the area with a knife. An incision is now made in the median line, 
from one tenaculum to the other, and the plane of separation between the 




FlG. 210.— Completion of the subcuticular 
suture of either the Emmet or Hegar per- 
ineorrhaphy. The end of the subcuticular 
suture is tied to the last crown suture. The 
knot is buried. 



INJURIES TO THE PERINEUM AND THEIR RESULTS 217 

anterior vaginal wall and the bladder determined by blunt dissection. The 
anterior vaginal wall is separated from the base of the bladder on each side 




K *3P 



Fig. 2ii. — Operation for complete tear of per- 
ineum. The apex of the rectovaginal tear is 
held up by a tenaculum. The sphincter pits 
are shown. 



Fig. 212. — Operation for complete perineal tear. 
The sphincter ends have been dissected; the 
denuded surfaces comprise the sphincter areas, 
the margin of the rectovaginal septum, the 
vaginal sulci, and the perineal body; the upper 
part of the denudation is after the Emmet 
perineorrhaphy. 



of the median incision as far as the lateral outlines and then excised 
(Fig. 215). 

The exposed base of the bladder is infolded by interrupted or running 
catgut sutures. The vaginal wall and the pubo-vesico-cervical fascia are 
brought together in the median line by continuous or interrupted catgut 
sutures (Figs. 216 and 217). 

The extent of this operation can be 
varied to suit the degree of relaxation 
that is present. When the cystocele is 
large, an inverted T-shaped incision 
should be made (Fig. 218). The dissec- 
tion between the bladder and the vagina 
should be continued posteriorly as far as 
the cervix; the bladder is separated from 
the cervix and pushed up (Fig. 220). 
The pubo-vesico-cervical ligaments 
(" bladder pillars ") and the cardinal liga- 
ments are exposed and developed bv blunt Fig 213— Suture of rectovaginal septum by 
c r J linen mtroduced from the rectal side. 

dissection (Fig. 221). The cardinal 

ligaments and the pubo-vesico-cervical ligaments are united to each other and. 

to the cervix in the median line beneath the bladder which is pushed up. 




218 



GYNECOLOGY 




Fig. 214.- — Operation for complete tear of perineum. Schematic diagram to show the 

introduction of the sutures. They are introduced in order as numbered. The end of the 

subcuticular suture, number eight, is continued forward to the junction of the perineal 

and vaginal surfaces where it is tied. 




Fig. 215. — Sanger anterior colporrhaphy ; the vag- 
inal wall and underlying fascia corresponding 
to the area outlined are being cut away. 



Fig. 216. — Sanger anterior" colporrhaphy: the su- 
ture is started at the anterior end of the incision 
on the vaginal surface; it embraces in each turn the 
fascia beneath the mucosa and the wall of the blad- 
der. Each transverse passage of the suture _ is 
half-hitched in order to prevent antero-posterior 
shortening; this suture is continued to the pos- 
terior limits of the denudation. 



INJURIES TO THE PERINEUM AND THEIR RESULTS 219 





Fig. 217. — Sanger anterior colporrhaphy. At 
the posterior limit of the incision the suture is 
carried through the vaginal wall and then con- 
tinued toward the starting point, each trans- 
verse passage catching the entire thickness of 
the vaginal mucosa and underlying fascia, and 
each one-half hitched to prevent anteropos- 
terior shortening. When the suture reaches the 
anterior limits of the vaginal incision it is tied. 
One strand of No. i, ten-day gut, one knot. 



Fig. 218. — Anterior colporrhaphy or 

cystopexy. Outline of initial incision 

in advanced cases. 




Fig. 219. — Anterior colporrhaphy or cystopexy. Exposure 

and separation of bladder from anterior vaginal wall and 

the cervix. 



Fig. 220. — Anterior colporrhaphy or cystopexy. 

Further separation of bladder from uterine wall, 

exposing vesico-uterine fold of peritoneum, bladder 

pillars and cardinal ligaments. 



220 



GYNECOLOGY 



Even in extensive cases this plan of operation will be satisfactory. If, 
however, the patient has passed the child-bearing period, other measures may 
be adopted that are more efficient, but partially or wholly incompatible with 
subsequent pregnancy and labor. One of these procedures consists of sepa- 
rating the bladder from the cervix beyond the uterovesical fold of the peri- 
toneum ; the bladder is then pushed up and its base united to the anterior 
surface of the body of the uterus above the internal os ; the bladder pillars 
and cardinal ligaments exposed on each side are brought together in the 
median line and attached to the anterior surface of the uterus below the 







Fig. 221. — Anterior colporrhaphy or cystopexy. Introduction of sutures, fixing the pubo-vesico- 

cervical fascia, "bladder pillars," and the cardinal ligaments to the cervix at the position of the 

internal os, and bringing the fascia together beneath the bladder. 

bladder ; the edges of the posterior extremity of the vaginal incision are now 
united by means of sutures to the cervix at about the position of the 
internal os. 

In very marked cases of cystocele GofTe sutures the base of the bladder 
to the uterus in the. median line and laterally to the broad ligaments. The 
line of attachment on the bladder is selected, so that all bulging downward 
is eliminated. 

Watkins' Interposition Operation. — In the case of very large cystoceles, 
in women past the menopause, the plan of operation elaborated by Watkins 



INJURIES TO THE PERINEUM AND THEIR RESULTS 221 



is the procedure of choice. In this operation the body of the uterus is 
interposed between the base of the bladder and the anterior vaginal wall. 
This method is applicable without modification only when the uterus is 





Fig. 222. — Interposition operation for prolapse. 
For steps in operation preliminary to this, see Figs. 
218, 210, 220. The vesico-uterine fold of perito- 
neum is split transversely and the fundus of the 
uterus pulled through the opening. 



Fig. 223. — Interposition operation. The bladder 
has been pushed up, the vesical peritoneum has been 
united to the posterior surface of the uterus at the 
internal os, and the fundus is being anchored to the 
fascia bordering the anterior extremity of the vagi- 
nal incision; the uterine body in this way is brought 
to lie beneath the bladder, between it and the 
vagina. 



small and freely movable, and when the adnexa are perfectly healthy. 
(See also pages 2~2 and 273.) After exposing the uterovesical fold of 
peritoneum the latter is divided trans- 
versely, opening the peritoneal cavity. 
The vaginal walls should be separated 
from the bladder somewhat extensively 
on either side of the median line. The 
fundus of the uterus is pulled forward 
through the peritoneal incision (Fig. 
222), while the base of the bladder is 
pushed upward so that the posterior 
surface of the uterus supports it. The 
upper edge of the vesico-uterine fold of 
peritoneum is attached to the posterior 
surface of the uterus somewhat above 
the position of the internal os. Sutures 
are passed between the anterior surface 
of the uterus and the adjacent margins 
of the pubo-vesico-cervical fascia, tri^ 6 : 22 ^ e ££^^<^^°^^ 
angular ligament and vaginal walls 

(Fig. 223) ; these fix the uterus in its new position (Fig. 224). The redun- 
dant portion of the vaginal mucosa is trimmed off, and the edges are united 
in the median line by continuous or interrupted catgut sutures. 




222 GYNECOLOGY 

BIBLIOGRAPHY 

Anspach, B. M. : " Buried Catgut and Subcuticular Stitch in Plastic Operations on the 

Perineum." International Clinics, vol. iv, eighteenth series, 1908. J. B. Lippincott, 

Phila. and London. 
Babcock, W. W. : " Submucous Perineorrhaphy." J. A. M. A., May 15, 1909, p. 1568. 
Emmet, T. A. : "A Study of the Etiology of Perineal Laceration, with a New Method 

for Its Proper Repair." Trans. Amer. Gyn. Soc, 1883, vol. viii, p. 198. 
Frank, R. T. : "A Study of the Anatomy, Pathology and Treatment of Uterine Prolapse, 

Rectocele and Cystocele." Surg., Gyn. and Obst., 1917, vol. xxiv, pp. 42-58. 
Goffe, J. R. : " An Improved and Perfected Operation for the Relief of Extreme Cases of 

Procidentia, Cystocele, and Rectocele." Am. Jour. Obst., 1910, vol. lxii, p. 611; Ibid.: 

" Operation for Extreme Cases of Procidentia, with Rectocele and Cystocele." Trans. 

Amer. Gyn. Soc, 1912, vol. xxxvii, p. 394. 
Goldspohn : " Fundamental Intrapelvic Perineorrhaphy." Trans. Sect. O. G. and A. S., 

A. M. A., 1914, p. 273. 
Hadra : " Remarks on Vaginal Prolapse, Cystocele, and Rectocele." Amer. Jour. Obst., 

May, 1889, vol. xxii, No. 5, p. 457. 
Hirst, B. C. : " The Technic of Pelvic Floor Repair." Ann. Surg., Phila., 1916, lxv, 247. 
Kelly, H. A. : " The Operation for Complete Tear of the Perineum." Amer. Jour. Obst., 

1899, vol. xl, No. 2. 
Noble, C. P. : " A Contribution to the Technic of Operations for the Cure of Laceration of 

the Pelvic Floor in Women." Amer. Gyn. and Obst. Jour., April, 1897 ; Ibid. : Plastic 

Operations. Kelly-Noble, vol. i. Saunders, Phila., 1907. 
Sanger, Max : " Zur Technik der Prolapsoperation." Centralbl. f . Gynak., 1898, vol. xxii, 

P. 33- 
Savage: "The Surgery, Surgical Pathology, and Surgical Anatomy of the Female Pelvic 

Organs," 2nd Ed., London, 1870. 
Sims, M. : Sims' Uterine Surgery, 1886, p. 205. Wm. Wood & Co., New York. 
Studdiford, W. E. : " The Involuntary Muscle Fibers of the Pelvic Floor." Trans. Amer. 

Gyn. Soc, 1909, vol. xxxiv, p. 759. 
Ward, G. G. : " An Operation for the Cure of Rectocele and Restoration of the Function 

of the Pelvic Floor." Trans. Amer. Gyn. Soc, 1913, vol. xxxviii, p. 169; Ibid. : "The 

Problem of the Cystocele." Amer. Jour. Obstet, 1919, vol. lxxix, No. 5. 



CHAPTER XIV 
DISEASES OF THE CERVIX 

Atresia of the cervix, in the vast majority of cases, is congenital, and 
manifests itself at puberty. Rarely, it may be acquired. A certain amount 
of stenosis of the cervical canal always occurs after the menopause. This 
may be complete, but, as a rule, a fine probe can be introduced. Actual 
atresia that obstructs the menstrual flow may be the result of cervix opera- 
tions, especially trachelectomy, the application of caustics, or decubitus 
ulcerations that have destroyed the mucosa. Atresia of the cervix during 
the reproductive period leads to retention of the menstrual fluid and the 
production of hsematometra, pyometra, or physometra. 

In patients approaching the menopause, atresia combined with intra- 
uterine collections of blood and pus is often indicative of malignant growths 
affecting the cervix or the body of the uterus. Acquired atresia of the cervix 
may be accompanied not only by hsematometra, but also by haematosalpinx. 
The symptoms vary. When it occurs during the reproductive period, there 
is recurring monthly distress, with little or no bloody discharge and the 
gradual enlargement of the uterus. In atresia appearing after the meno- 
pause, there are no symptoms unless the uterine cavity is the seat of car- 
cinoma or sarcoma, when the bloody discharge cannot escape, and there is the 
gradual formation of an hsematometra or a pyometra. (See Chapter XVI.) The 
diagnosis is established by the passage of a probe, if necessary, under anaesthesia. 

In non-malignant cases the treatment consists in relieving the obstruc- 
tion by forcibly dilating the cervix, and performing such other operative treat- 
ment as may be required, which is described under gynatresia. In 
malignant cases the establishment of drainage is the first indication, to be 
followed by pan-hysterectomy if the case is operable. 

Endocervicitis. — Hyperplasia of the cervical mucosa may be the result 
of mechanical irritation after laceration and eversion of the cervical lips. 
Under such circumstances the lesion consists of a hypertrophy of the cer- 
vical glands, the discharge being a hypersecretion. Actual infection of the 
cervix occurs in acute gonorrhoea and in post-partal, post-abortal, and post- 
operative infections. The acute disorder is usually accompanied by lesions 
that greatly overshadow it in importance, as, e.g., an acute endometritis, 
metritis, or cellulitis, or it may be but one of an associated series of lesions, 
as in gonorrhoea. A discussion of the acute cervical infections will be found 
under the head of Gonorrhoea, Chapter XXIX, and Pelvic Inflammatory 
Disease, Chapter XXI, to which the reader is referred. 

We are concerned here only with chronic cervical infections. This is 
most frequently of gonorrhoeal origin. A staphylococcus or a streptococcus 
infection, once the acute attack is over, rapidly subsides and gives little 
further trouble except in so far as it leaves behind tissue that has been 
either altered in form or permanently injured. The infectious agent, 
however, disappears. 

223 



224 



GYNECOLOGY 



Chronic gonorrhoea of the cervix may, on the other hand, be exceedingly 
resistant to all forms of treatment, and may remain partially latent, but 
none the less infectious, for many years. In many cases the gonococcus is 
most difficult to find, and no history of gonorrhceal infection or exposure can 
be elicited. In some of these cases it is possible that the original infection 
took place during infancy. 

Chronic endocervicitis is evidenced by a thick, mucopurulent discharge, 
and an erosion of the mucosa about the external os. The more chronic the 
condition, the fewer in number the pus-cells, and in old cases that per- 
sist because of the hypertrophy that remains as the residuum of the previous 
inflammation, the discharge may consist almost entirely of mucus. Careful 
and repeated examinations of smears, however, made just before or just after 
menstruation, will usually show the presence of pus-cells and of gonococci. 

In addition to the discharge, which may be so profuse as to require the 
patient to wear a perineal dressing to protect the clothing, the menstrual 





Fig. 225. — Cervical polyp of large 
size projecting from the external os. 



FlG. 226. — Cervical polyps, showing origin 
from mucous plicae of the cervix. 



periods may be profuse and painful, and the patient may complain of a sense of 
weight and discomfort in the pelvis. 

The treatment should be directed toward establishing complete and easy 
drainage, and the employment of suitable disinfecting solutions. In the 
nulliparous woman, when the external os is constricted and the cervical 
canal becomes rilled with the thickened secretion, it will be found advan- 
tageous to split the lips of the cervix so as to expose the entire mucosa, 
thus insuring free drainage and permitting applications of disinfecting solu- 
tions to be made. 

The cervical mucus should be coagulated or toughened by applying a 
solution of silver nitrate, when it may be withdrawn from the canal with a 
dressing forceps. Another method is. to dissolve the cervical mucus by 
applying a 10 per cent, solution of sodium hydroxide. The mucosa being ex- 
posed, the disinfecting agent is then applied directly. Pure phenol, fol- 
lowed by alcohol and silver nitrate (10 to 20 per cent.) followed by salt 
solution, are the most effectual means of disinfection. Tincture of iodine, 
pure ichthyol or argyrol, 25 per cent., may also be tried. Such applications 



DISEASES OF THE CERVIX 



225 



should be followed by the introduction of tampons medicated with ichthyol, 
25 per cent, in petrolatum. 

After the tampons have been removed, hot douches should be adminis- 
tered, and the treatment repeated three times a week. Under this method 
the discharge will usually subside. In obstinate cases operative treatment 
will be required. Curettage of the endometrium and cervix, together with 
the application of pure phenol, followed by alcohol, may be sufficient. If, 




Fig. 2: 



-Elongation and hypertrophy of cervix resembling prolapsus uteri. 



however, the cervical lips are hypertrophied or are the seat of Nabothian 
cysts, amputation should be performed. (See also Gonorrhoea, Chapter 
XXIX, for prognosis.) 

In obstinate endocervicitis Hunner recommends linear cauterization of 
the cervical mucosa with the electric cautery. Destructive cauterization of 
this type or deep cauterization by means of powerful chemicals is objection- 
able because of the scar tissue and stenosis that are prone to ensue. 

Cervical Polyp. — Polypoid outgrowths may occur from the mucous raem- 
15 



226 GYNECOLOGY 

brane of the cervix, varying in size from that of a pea to an English 
walnut. These little tumors are composed of a fibrous tissue stroma and 
contain glands that resemble those of the cervical mucous membrane (Fig. 
225). The growths are, as a rule, pedunculated. They begin as localized 
hypertrophies of the mucosa that gradually increase in size and become 
pedunculated (Fig. 226). The polyp may be entirely concealed within the cervi- 
cal canal, or it may present at the external os or project from the cervix into 
the vaginal vault. Small polyps springing from the cervical canal are 
usually covered with high columnar epithelium ; those originating about the 
external os may exhibit surface epithelium of the squamous type. When 
the polyp is large and projects from the cervix, the surface epithelium is 
usually rubbed off by contact with the vaginal vault. If the polyp springs 
from the mucosa near the position of the internal os, the tumor may con- 
tain glands that resemble those of the endometrium more than those of the 
cervical mucosa. Polyps of considerable size are often extruded from the 
cervical canal, in which event the stretching of the pedicle may interfere 
with the blood supply of the growth, resulting in necrosis and gangrene. 

The symptoms consist of the discharge of a thick, mucilaginous secre- 
tion, occasionally streaked with blood, increased -menstrual flow, and intra- 
menstrual hemorrhage following defecation, coitus, or vaginal irrigations. 
The diagnosis is easily made : on exposing the external os a bright red 
tumor, varying in size from a pea to a walnut, will be seen projecting from, 
or lying within, the orifice. Rarely it may be necessary to dilate the exter- 
nal os before the polyp can be brought into view. 

The tumor may be grasped with forceps and removed by torsion or 
avulsion of its pedicle, or, if the pedicle is accessible, it may be ligated and the 
tumor removed with scissors. As these polyps not infrequently display a 
tendency to undergo malignant change, it is usually advisable, except in 
very young women, to administer a general anaesthetic, and, after removing 
the polyp, curette the entire uterus thoroughly, and examine both the polyp 
and the endometrial scrapings microscopically. 

Cancer of the Cervix. — See Cancer of the Uterus. 

Atrophy of the Cervix. — See Malformation of the Cervix. 

Myomata of the Cervix. — See Myomata of the Uterus. 

Stenosis of the Cervix. — See Pathologic Anteflexion of the Uterus. 

Tuberculosis of the Cervix. — See Tuberculosis of the Pelvic Organs. 

LACERATIONS OF THE CERVIX 

Pathology. — A tear of the thinned-out rim of the cervix occurs almost in- 
variably during the first stage of labor. Although the laceration is not, as a rule, 
very extensive and heals without leaving any ill effects, some widening 
of the external os and slight exposure of the cervical canal generally 
occur. Furthermore, in a woman who has borne children it is nearly always 
possible to detect scars upon the cervix (Figs. 228 to 231). Lacerations 
of the cervix usually take place to one side of the os, in the plane between 
the anterior and the posterior lip. A tear may affect only one side (uni- 
lateral) or both sides (bilateral) may be involved. Bilateral lacerations 



DISEASES OF THE CERVIX 



227 



may be accompanied by tears involving the anterior or the posterior lip, 
the combined laceration being designated as stellate (Fig. 232). In many 
instances extensive lacerations of the cervix are the evidence that forceps 
operations were undertaken without full dilatation of the cervix. 

When the laceration is bilateral or stellate, or unilateral and deep, the 
lips of the cervix are inclined to separate, somewhat like the split end of a 
stalk of celery (eversion) (Fig. 233). This separation of the cervical lips 





FlG. 228. — NulHparous cervix. FlG. 229. — Parous cervix; well Fig. 230. — Parous cervix; well 
healed bilateral laceration, plug of healed bilateral laceration, 

mucus in cervical canal. 

tends to prevent healing by first intention and granulation, and the entire 
or the greater extent of the wound undergoes cicatrization. This results in 
more or less permanent alteration in the shape of the cervix : the cervical lips 
remain separated, mucous membrane from the vaginal surface of the cervix 
or from the cervical canal grows over the lacerated surfaces, and a consider- 
able amount of scar tissue is formed beneath the mucosa, espcially at the 
angles or at the upper limits of the laceration. 







Fig. 231. — Deep unilateral lacera- 
tion with irregular tag of cervical 
tissue. 



Fig. 232. — Stellate laceration. 



As a consequence of the permanent eversion the cervix is increased in its 
anteroposterior diameter, and the cervical canal is exposed (Fig. 234). 

The exposure of the cervical mucosa and the traumatism to which it is 
subjected, especially if there is associated prolapse of the pelvic floor or dis- 
placement of the uterus, result in an irritation and hypersecretion of the 
cervical glands — the so-called " catarrh of the cervix." In many instances a 
low-grade inflammation of the mucous membrane is present, accompanied 



228 



GYNECOLOGY 



by occlusion of the gland-ducts and the formation of small growths which 
are known as Nabothian cysts. These vary in size from a pinhead to a pea, 
and rarely may be a centimeter or two in diameter (Fig. 235). 

Accompanying low-grade inflammation of the cervical mucosa there is 
often hypertrophy of the fibromuscular tissues of the cervix, which is par- 





FiG. 23.3. — Deep bilateral laceration 

with unequal division of cervical 

lips; e version. 



Fig. 234- — Deep bilateral laceration with ever- 
sion of lips, cystic degeneration and hyper- 
trophy. 



ticularly apt to be marked when Xabothian cysts are present (Fig. 234). 
Thus, in the course of events, and solely as the result of a laceration, the 
cervix may become considerably increased in size and in density. As the 
result of walking, defecation, urination, etc., the epithelium of the exposed 
surface mav be rubbed oft from certain areas that come in contact with the 





Fig. 235. — Xabothian cysts of cervix. 



Fig. 236. — Xulliparous cervix, exten- 
sion of cervical mucosa beyond ex- 
ternal os to vaginal surface of the 
cervix. The so-called erosion of Ruge 
and Veit. 



vaginal mucosa. This condition is known as erosion. As a rule, it is merely 
superficial, but in cases of prolapse, when the cervix projects from the 
vaginal introitus, it is exposed to external trauma and deep ulcers (decu- 
bitus) may form. 



DISEASES OF THE CERVIX 



229 



Hypertrophy of the Cervix. — Although hypertrophy of the cervix is usu- 
ally a sequel of laceration with eversion and low-grade infection, it may be 
due to other causes. Among these may be mentioned chronic endocervicitis 
with cystic distention of the glands, and displacement of the cervix, as in 
prolapse, with its resulting circulatory disturbance and exposure to trauma 
(Fig. 234). 

In some cases of prolapse hypertrophy, especially elongation, is more 
apparent than real. Inversion of the vaginal fornices and their close application 
to the descending uterus may resemble a true hypertrophic elongation, but 
if the patient is placed in the knee-chest position and the uterus is displaced 
upward toward the abdominal cavity, the actual length of the vaginal portion 
of the cervix can be determined by inspection of the vaginal fornices. 





Fig. 237. — Nulliparous cervix. No erosion and no laceration. The cervical mucosa is 

not exposed. 





Fig. 238. 



-Parous cervix. Deep bilateral laceration with eversion of the cervical lips and 
exposure of the cervical mucosa. 



Hypertrophic elongation of the vaginal cervix is occasionally observed 
in uninfected nulliparous women. The cervix projects well into the vagina, 
and may even present at the vaginal outlet (Fig. 227) ; when this occurs, 
inspection of the presenting part reveals nothing abnormal beyond elonga- 
tion ; i.e., the distance from the os to the vaginal fornices is considerably 
increased. The vaginal fornices maintain their original position, and the 
hypertrophic elongation affects the cervix below its vaginal attachment. 

Symptoms and Results of Laceration of the Cervix. — The common- 
est symptom of a lacerated and everted cervix is a leucorrhoeal dsicharge. 
This is somewhat thick and tenacious, and varies in amount, at 
times being scarcely more than noticeable, and at others being so profuse 
as to be a source of constant annoyance. When there is no infection it may 



230 GYNECOLOGY 

be made up of mucus alone, but when an infection exists it consists of 
mucus mixed with pus. When endocervicitis, Nabothian cysts, and hypertrophy 
complicate the laceration, the menses may be profuse and painful. As a 
matter of fact, lacerations of the cervix associated with hypertrophy and 
Nabothian cysts are frequently accompanied by displacement of the uterus 
and relaxation of the perineum, so that, in addition to the symptoms men- 
tioned, the patient presents those of displacement and loss of support. 

Diagnosis. — Upon inspection the rounded, knob-like normal cervix cov- 
ered with mucous membrane of the same color as the vaginal vault is no 
longer visible, but in its stead the cervix is seen to be more or less ellipti- 
form in outline ; the anterior and posterior lips diverge, and the bright red 
mucosa of the cervical canal, which contrasts sharply with the duller hued 
mucosa of the vaginal cervix, is exposed (Fig. 239). At first sight, this 
presents the appearance of an ulcerating surface. 

The cervix and vaginal vault frequently are bathed with a profuse dis- 
charge, which, if there is no infection, may be clear and gelatinous — pure 

mucus ; or, if the opposite is true, it may be 
yellowish and almost entirely purulent. Some- 
times the cervical mucosa has overgrown the 
angles of the laceration, so that many varia- 
tions in the appearance of the cervix may 
occur. If there are Nabothian cysts (Fig. 
235) sago- or tapioca-like bodies may be seen 
embedded in the cervix ; these have a slightly 
bluish, translucent appearance, shimmering 
through the surface of the mucosa, and feel- 
ing like shot embedded beneath it. 

The formation of Nabothian cysts is fre- 
quently accompanied by hypertrophy, so that 

Fig. 239- — Deep bilateral laceration, \ . t ,. , \ 1 1 i • 

with eversion of the cervical lips and the cervical lips become enlarged and their 

exposure and inflammation of the cervi- . .. j -1*7-1 .• j 

cai mucosa. density increased. When cystic degeneration 

is marked, eversion of the cervical lips and expo- 
sure of the cervical mucous membrane are less noticeable ; the outline of the 
cervix is rounded, but irregular, owing to the shot-like cysts, and the cervi- 
cal tissue is very hard and sclerotic. 

When badly lacerated and complicated by eversion and erosion, the 
cervix may, upon superficial examination, strongly resemble a beginning 
carcinoma or an ulcerative lesion of tuberculosis or syphilis. The exposed 
cervical mucous membrane may bleed slightly when touched by the finger 
or wiped with a pledget of cotton. Close inspection, however, will usually 
disclose the fact that the folds of the cervical mucous membrane are regular, 
and that the arbor-vitse-like arrangement of the plicae is preserved. 

Actual destruction of the mucous membrane and of the underlying tissues 
by ulceration probably never occurs unless carcinoma, tuberculosis, or 
syphilis is present. As previously noted, an exception may be made in cases 
of laceration associated with marked descensus or prolapse, when there may 
be an ulceration that is clearly the result of the mechanical insults to which 
the cervix is subjected. 




DISEASES OF THE CERVIX 



231 



The true nature of bilateral laceration with eversion may be shown by 
grasping each lip of the cervix at the junction between the bright red and 
the duller mucous membrane, and bringing these points together (Figs. 240 
and 241). This manceuver temporarily restores the external os, and approxi- 
mates the anterior and the posterior lip. It causes a disappearance of the 
bright red mucosa, and demonstrates that it is nothing more than the ex- 
posed membrane of the cervical canal. When the eversion is associated 
with hypertrophy of the cervical lips, this test will fail. In such cases the 
diagnosis of a benign condition may be assumed from the fact that the 
tissue is not friable and that stony induration is absent. Nabothian cysts 




Fig. 240. — A test to show that the red. angry-lookins? surface is the cervical mucosa ex- 
posed by the eversion of the lips. Indication for trachelorrhaphy, not trachelectomy. 








Fig. 241. — Deep bilateral laceration. Eversion of the mucosa. Nabothian cysts 

and exposure of the cervical mucosa. Amputation (trachelectomy), not repair 

(trachelorrhaphy), must be selected here. 

are diagnosed by their appearance and by means of palpation ; in doubtful 
cases the diagnosis can be confirmed by puncturing the cysts, when their 
contents will be at once expressed. 

All lesions of the cervix of doubtful quality should be at once subjected 
to diagnostic curettage and excision of tissue. The technic of this procedure 
has been discussed elsewhere (page 121). 

Treatment. — The treatment of laceration of the cervix, with or without 
eversion, cystic degeneration, or hypertrophy, depends upon the extent of 
the tear, the severity of the symptoms, the age of the patient, and the pres- 



232 



GYNECOLOGY 



ence of associated lesions. In the active child-bearing period uncomplicated 
cases should receive only such local treatment as is required to render the 
patient comfortable. After the next puerperium trachelorrhaphy may be 
performed. In women approaching the menopause, a cervical disorder 
should be subjected to operation without delay. When operative treat- 
ment for other lesions of the reproductive organs or abdomen is required, a 
diseased cervix should receive surgical attention whether or not it is giving 
rise to acute symptoms. The symptoms of a diseased cervix (leucorrhcea, 
menorrhagia, dysmenorrhoea, etc.) may be so annoying and so little affected 
by palliative treatment that operation is indicated forthwith, whether fur- 
ther reproduction is contemplated or not. 

Except where the indications for operation are urgent, it is a good plan 

to try palliative measures before resorting to 
operative treatment. Applications of 
Churchill's tincture of iodine, made directly to 
the cervix, followed by the introduction, into 
the vaginal vault, of boroglyceride tampons 
and the use of hot douches, may relieve the 
congestion and tend to lessen the discharge. 
Nabothian follicles that project prominently 
may be opened with a bistoury and their cavi- 
ties swabbed with pure phenol. By this pre- 
paratory treatment the cervical tissues are 
placed in a condition that favors union by first 
intention after operation. QEdema, erosion, 
and cystic distention are temporarily relieved, 
giving the surgeon a better opportunity to esti- 
mate correctly the amount of tissue to be 
removed. 

The operative treatment consists of per- 
forming either trachelorrhaphy or trachelec- 
tomy — the former when there is no disease of 
the cervical muscle itself and the cervical 
glands have not undergone extensive cystic 
degeneration, and the latter when the cervical 
lips are hypertrophied and cystic degeneration 
is marked. The operation of trachelorrhaphy (Figs. 242, 243, and 244) first 
reproduces the cervical laceration, and then reforms the cervix by uniting the 
torn surfaces. Trachelectomy (Figs. 245, 246, and 247), or amputation of the 
cervix, actually removes the hypertrophied and diseased parts of the cervical 
lips, forms a new external os, and shortens the entire cervix (Fig. 247). 

Trachelorrhaphy is applicable only to lacerations that are accompanied 
by little or no hypertrophy, cyst formation, or infection of the cervix — in 
other words, to those in which a denudation of the original traumatized area 
and the introduction of sutures approximating the edges will restore the 
normal contour of the cervix. The actual removal of a part or of the entire 
cervix is demanded where trachelorrhaphy alone is not sufficient to remove 
the diseased tissue. Trachelectomy is also employed in connection with 




Fig. 242. — Trachelorrhaphy; repair. 

The apex of the angle of laceration on 

both sides is split to a point well above 

the scar tissue. 



DISEASES OF THE CERVIX 



233 




Hf.fc 



The 



operations for prolapse in women who have passed the menopause, in order 
to eliminate the cervix as a possible cause of recurrence. When it is al- 
lowed to remain, the cervix may act like the acorn tip on a bougie and 
serve to guide the uterus down through the vaginal tract. The removal of 
the cervix may, therefore, be one of the 
necessary operative measures selected in 
the treatment of prolapse. 

Whenever possible, trachelectomy 
should be avoided during the child-bear- 
ing period, as it predisposes to abortion 
in subsequent pregnancies and to dystocia 
in subsequent labor. The preliminary 
treatment of a diseased cervix by the ap- 
plication of tampons, puncture of cysts, etc.. 
will sometimes permit the surgeon to substi- 
tute trachelorrhaphy for trachelectomy. 

Trachelorrhaphy. — This operation is 
performed as follows: After the custom- 
ary disinfection of the operative area, the 
cervix is exposed with a Sims' speculum. 
The anterior and the posterior lip are each 
caught with a tenaculum in the median 
line, at a point that corresponds to the 
original location of the external os. The 
cervical lips are separated and the lacer- 
ated area is exposed. The area for de- 
nudation is now outlined by making an 
incision on either side of the median line 
of both lips, from the external os to the 
position occupied by the original external 
os (Fig. 242). The lines should be run 
parallel and be about one-quarter of an 
inch apart. They bound a strip of that 
width which is left undenuded, and which 
constitutes the lining of the reconstructed 
cervical canal. The parallel median in- 
cisions are continued from their anterior 
termination outward, along the border of 
the lacerated area to a point above its 
upper limit, the incision on the anterior 
and the one on the posterior lip joining on the 

lateral surface of the cervix, well above the angle of laceration, and close to the 
attachment of the vaginal fornix. The areas thus outlined are next denuded by 
means of tissue forceps and a scalpel or by sharp-pointed scissors. Particular 
care should be taken to remove all the tissue at the apices of the cervical tear. 
After a clean denudation on either side has been effected, sutures are introduced 
for the purpose of approximating the denuded areas of the anterior to those of 
the posterior lip. The first suture is introduced at a point directly opposite 



Fig. 243. — Tracnelonhapny; repair, 
vical lips are denuded except for a strip of mu- 
cosa in the midline of each one at the site of the 
new cervical canal. The sutures are introduced 
as indicated. 




Fig. 244.- 



1 rachelorrhaphy 
upper sutures are tied; the 



repair. 



The two 
everted lips are be- 
ing approximated. The cervical canal has been 
almost entirely restored. 



234 



GYNECOLOGY 



the upper limit of the denudation. The needle is inserted into the mucous 
membrane of the vaginal surface of the cervix, being carried under the 
denuded area of the posterior lip, and emerges just on the border of the 
undenuded strip that is to form the new cervical mucosa. It is reintroduced 
at a point opposite on the anterior lip, and carried through in a reverse direc- 
tion to a corresponding point (Fig. 243). A succession of sutures is intro- 
duced from above downward until the entire length of the denuded area is 
approximated. After the sutures have been placed on one side, the same 
method is pursued upon the other. No sutures are tied until all have been 
introduced. The anterior and posterior lips of the cervix should be approxi- 
mated with only slight tension. When the sutures are tied, the external 
shape of the cervix will have been restored to its original form, the exposed 




Fig. 245. — Trachelectomy: amputation of 
cervix, showing the cervical lips split 
laterally to the level of the proposed am- 
putation; lines of excision of the cervical 
lips outlined. 




Fig. 246. — Trachelectomy; amputation of cervix. 
The cervical lips have been excised; flaps must 
now be brought together with sutures, so passed 
that there will be a new external os and that 
all raw surfaces will be covered. The groups of 
sutures are passed as marked alphabetically. 



and everted mucous membrane will no longer be visible, and the external os 
will be in its normal position (Fig. 244). 

Trachelectomy. — For the operation of trachelectomy the cervix is ex- 
posed, and each lip is caught with a tenaculum. The cervix is then pulled 
down, and an estimate is made of the amount of tissue to be removed. When 
considerable hypertrophy is present, and especially if the condition is asso- 
ciated with a marked descensus or a prolapse, a high amputation is per- 
formed. If, however, the patient is a young woman, and it is desirable to 
save as much of the cervix as possible, a low amputation is indicated. The 
difference between the two operations lies in the amount of cervical tissue 
that is removed, and in the position of the outer cervical incisions. 

If a high amputation is to be done, the operation is begun by making an 
incision completely around the cervix, dividing the vaginal mucosa at the 
point where it is reflected from the vaginal fornices over the vaginal cervix. 



DISEASES OF THE CERVIX 235 

After this circumcision the vaginal tissue is separated from its attachment 
to the cervix all around, and as high up as it is desirable to amputate. The 
cervix is then split laterally to the corresponding point, and by means of a 
wedge-shaped incision that forms an inner and an outer flap, each lip 
is removed. 

In a low amputation the wedge-shaped incision and the formation of 
flaps are carried out without a preliminary detachment of the vaginal for- 
nices from the cervix, the line of amputation falling well within the cervico- 
vaginal junction. Whichever form of operation is selected, the plan 
of introducing the sutures is about the same. The object is to cover 
the raw surfaces and fashion a new external os. The first suture is intro- 
duced in the median line posteriorly (Fig. 246), the needle being carried 
through the cervical mucosa, passing to the depths of the wedge-shaped 
incision, and withdrawn and then reinserted, passed through the remaining 
posterior part of the cervical lip, and, in the case of high amputation, addi- 
tionally, the corresponding part of the posterior vaginal fornix. One suture 




Fig. 247. — iracnelectomy; amputation of cer- 
vix. Sutures tied; there is now a new external 
os and all raw surfaces are covered. ' 

is introduced on each side of this single median suture. Similar sutures are 
now introduced anteriorly, and the two sets together serve the purpose of 
uniting the mucosa of the vaginal surface of the cervix to the mucosa of the 
cervical canal, thus insuring the formation of an external os (Fig. 247). 
The lateral sutures are now introduced, their purpose being simply to ap- 
proximate the raw areas on either side. The first suture is the uppermost, 
and extends from a point on the posterior lip immediately behind the upper 
limits of the excision, beneath the raw area of the posterior lip, into the 
cervical canal. From this point it is reintroduced through the cervical 
mucosa, and made to traverse the tissues of the anterior lip in an opposite 
direction. This suture approximates and embraces the depths of the cervi- 
cal incision and is haemostatic. The other lateral sutures are introduced in a 
corresponding manner, but in a more antero-posterior direction, care being 
taken to have them pass beneath all the raw tissue. No sutures are tied 
until all have been introduced, unless the hemorrhage is marked, when the 
haemostatic suture may be tied at once. 



236 GYNECOLOGY 

active hemorrhage from the wounded branches of the uterine artery and 
vein. In passing the haemostatic suture care must be taken lest the needle 
be passed so deeply as to catch the ureter. If the lines of incision are 
correctly placed, there is little tension on the sutures when they are tied. 

BIBLIOGRAPHY 

Emmet, Thomas Addis : " Surgery of the Cervix in Connection with the Treatment of 
Certain Uterine Diseases." Am. Jour. Obst., 1869, vol. i, p. 339 ; Ibid. : " Laceration of 
Cervix as a Frequent and Unrecognized Cause of Disease." Amer. Jour. Obst., Novem- 
ber, 1874 ; Ibid. : "The Proper Treatment for Laceration of the Cervix." American 
Practitioner, 1877, vol. xv, p. 1. 

Leonard, V. N. : " The Post-operative Results of Trachelorrhaphy in Comparison with 
Those of Amputation of the Cervix." Surg., Gyn. and Obst., 1914, vol. xviii, p. 35. 

Noble, C. P. : " Ectropion of the Cervix in Nulliparae Resembling Laceration of the Cervix." 
Amer. Gyn. and Obst. Jour., February, 1897, p. 135. 

Penrose, C. B. : " Congenital Erosion and Split of the Cervix Uteri." Amer. Jour. Med. 
Sciences, May, 1896, p. 503. 

Sims, J. M. : "Amputation of the Cervix Uteri." Trans. Med. Soc, State of N. Y., 1861, 
p. 367. 



CHAPTER XV 
CHANGES IN FORM AND POSITION OF THE UTERUS 

Normally, the axis of the body of the uterus forms an obtuse angle with 
the axis of the cervix. The body of the uterus is flexed forward on the 
cervix; this is known as anteflexion (Fig. 248). If the conditions are re- 
versed and the uterine body is bent backward on the cervix, the relation 
between the body and the cervix is known as retroflexion. When the axis 
of the entire uterus is turned forward, swinging on an imaginary transverse 
line passing through the cervix at the level of the internal os (Fig. 249), the 
uterus is said to be anteverted (Fig. 250). When the axis of the entire 
uterus is turned backward, the organ is said to be retroverted (Fig. 250). 




Fig. 248. — Diagrammatic sagittal section, showing Fig. 249. — Schematic outline, showing arc of imagin- 

normal anteflexion and anteversion of the uterus. ary circle through which fundus moves during ante- 
version and retroversion; also the point at the inter- 
nal os which represents the imaginary transverse- 
axis on which the fundus rotates forward or back- 
ward. The pull of the round ligaments forward 
above the axis and the pull of the utero-sacral back- 
ward below the axis have the same effect on the 
uterus; it maintains anteversion. 

Anteversion is usually combined with anteflexion, and both are normal ; 
retroversion is usually combined with retroflexion, and both are pathologi- 
cal (Fig. 251). Occasionally anteflexion is so marked or is accompanied by 
such ill or faulty development of the cervix as to give rise to certain symp- 
toms ; this is known as pathologic anteflexion (Fig. 252). The uterus may 
also be latero-flexed or latero-verted, or both combined, as the result of 
faulty development, from the pressure of tumors, or from the tug of adhe- 
sions or thickened ligaments. Anteposition, retroposition, and right or left 
latero-position indicate total displacement of the uterus forward, backward, 
or to one side by pelvic tumors, exudates, or adhesions. 

237 



238 



GYNECOLOGY 



The uterus may be totally displaced downward. As soon as the uterus 
drops below its normal level in the pelvis the condition is termed descensus 
uteri (Fig. 253) ; when it drops further down, it is known as prolapsus uteri; 




Fig. 250. — The normal position of the uterus (A) ; 
extreme anteversion (B), and retroversion (C). 
The uterus remains anteflexed in all. The direc- 
tion of intra-abdominal pressure is indicated by 
the arrows. 



Fig. 251. — Retroflexion and retroversion of the 
uterus (broken lines). The uterus is turned back- 
wards on the imaginary transverse axis passing 
through the cervix; the axis of the fundus is flexed 
backward on the axis of the cervix. Intra-abdominal 
pressure strikes the uterus on its anterior wall. 



if the downward displacement is extreme, so that the uterus projects out- 
side the body, the condition is known as procidentia (Fig. 285). 

The normally anteverted and anteflexed uterus does not commonly undergo 
downward displacement. Preceding descensus the axis of the entire uterus 
turns backward and corresponds more or less with the axis of the 

vagina. In some cases this retroversion 
is very slight, and the uterus may still be 
anteflexed, but the uterine axis is sufficiently 
posterior to permit its descent. 

The uterus may be entirely elevated 
above its normal position by the traction of 
adhesions or the growth of a tumor. It 
may also form part of the contents of a 
hernial sac. 

The displacements of most practical in- 
terest and importance are pathologic ante- 
flexion, retroversio-flexion, descensus, and pro- 
lapse. In other forms of displacement the 
position of the uterus is, with few exceptions, 
entirely secondary to the associated pelvic 
lesion, as, for example, anteposition from the 
occupation of Douglas' pouch by an ovarian cyst, or elevation of the uterus 
by the tug of a subperitoneal fibroid fixed above the pelvic brim. 




Fig. 252. — Pathologic anteflexion with 
associated ill-developed cervix and nar- 
row canal 



CHANGES IN FORM AND POSITION OF THE UTERUS 239 

PATHOLOGIC ANTEFLEXION OF THE UTERUS 

Pathology. — Anteflexion is regarded as pathologic when it is of marked de- 
gree and accompanied with sufficient obstruction of the cervical canal to cause 
dysmenorrhcea and sterility (Fig. 252). At times the cervical canal is 
abnormally narrow, although the anteflexion of the uterus, as determined 
by bimanual examination, is not more marked than usual, and occasionally, 
even though the anteflexion seems more marked than normal, symptoms 
of obstruction may not exist. Cases of exaggerated anteflexion are usually 




Fig. 253. — Retroversion. Slight flexion and descensus and beginning of prolapse: pressure on rectum; 

hemorrhoids and constipation. The pressure of the uterus on the rectum causes an accumulation of 

fseces, and this in turn aggravates the descensus of the uterus. Rectocele and cystocele. 

associated with shortness of the anterior wall (Fig. 255), a small uterus, 
and a long, conical imperfectly developed cervix. The ligaments of the 
uterus may be in a state of spastic contraction, whereby the strong for- 
ward pull of the fundus by the round ligaments, the traction backward 
of the uterosacral ligaments on the isthmus, and the forward fixation 
of the cervix by a short anterior vaginal wall combine to form an acute 
angle between the uterine cavity and the cervical canal. Furthermore, 
when this spasticity is relieved by anaesthesia, the degree of flexion is 
diminished and the amount of stenosis or obstruction of the cervical canal is 
less marked. 



240 



GYNECOLOGY 



Symptoms. — The symptoms in pathologic anteflexion may be due not only 
to obstruction of the cervical canal, but also, in part, to a faulty development 
of the uterine muscle (too great a proportion of fibrous tissue), or of its 
vascular and nervous supply (see Dysmenorrhoea). The condition is usually- 
congenital, and the symptoms commonly appear with the onset of menstrual life. 1 

The principal symptoms of pathologic anteflexion are dysmenor- 
rhoea and sterility. Pain begins a few hours to a day before the onset 
of the menstrual flow, and may be exceedingly severe for the first 
six to twelve hours of the flow, after which it gradually subsides. In addi- 
tion to this form of pain, typical of obstruction, there may be the more 
continuous distress, lasting for several days, which is the result of an asso- 
ciated imperfect development of other pelvic structures. Similarly the 




Fig. 254. — Schematic outline . showing uterus in 
normal position, ante-position and retroposition. 
There is no change in the normal anteflexion or 
anteversion but the uterus is bodily pushed for- 
ward, (A) or backward, (B). This is almost always 
the result of pelvic tumors lying in front of, or back 
of. the uterus. 



Fig. 255. — Schematic, outline showing the influence 
of a shortened anterior vaginal wall in the produc- 
tion of a retroflexio- version of uterus. Cervix pulled 
forward causes the uterus to turn backward on its 
transverse axis passing transversely through the 
cervix ; as soon as the backward displacement begins 
intra-abdominal pressure strikes the anterior wall of 
the uterus and presses the fundus further backward. 



sterility, although primarily ascribed to stenosis of the cervical canal, may 
be the result, in part, of faulty development of the uterine body, imperfectly 
developed ovaries, or abnormal tubes. 

1 Reynolds declares that in many cases of hypoplasia of the uterus — so-called infantile 
uterus — there is a corresponding lack of development of the anterior vaginal wall, and of 
a fascia, described by Goffe, which runs from the cervicovaginal attachment to the pubic 
arch on each side of the urethral canal. This is a Y-shaped ligament, which holds the 
cervix forward in its vaginal position. The uterosacral ligaments attached above this 
posteriorly pull back on the supravaginal cervix. The round ligaments tilt the fundus 
forward, thus producing angulation in the supravaginal cervix. When menstruation 
occurs, the uterus attempts to straighten out and relieve the angulation. This can occur 
only by relaxation of the yielding supports, i.e., the round ligaments which are in 
part muscular. 

To relieve this condition Reynolds proposes to lengthen the anterior vaginal wall by 
making a transverse incision in the vaginal mucous membrane, split the fascial bands of 
Goffe transversely, and suture the wound longitudinally. The cervix is then subjected 
to a Pozzi or a Dudley operation, or a simple splitting is performed, and the uterus sus- 
pended by a round ligament operation. This investigator makes a strong point of noting 
the motility or mobility of the cervix in such cases, and advises that this plan be -followed 
in all such cases so that the cervix will drop back into the posterior vaginal fornix. 



CHANGES IN FORM AND POSITION OF THE UTERUS 241 



Diagnosis. — A simple digital vaginal examination shows the cervix to be 
well back in the vagina, small in size, and conic in shape, with a minute 
depression in its extremity that marks the site of the external os (Fig. 120). In 
front of the cervix, through the anterior vaginal wall, the angle of flexion between 
the body of the uterus and the cervix may at times be made out. The 
cervix points forward directly in the axis of the vagina. On bimanual 
examination the vaginal finger pressed upward from the anterior vaginal 
wall, and the abdominal fingers pressed downward above the symphysis pal- 
pate the body of the uterus in an- 
teflexio-version between them. '„ 
The angle between the cervix and 
the body is markedly acute (Fig. 
124). The entire uterus is small, or 
the body is disproportionately small, 
whereas the cervix is long and nar- 
row. As a rule, the adnexa show 
no abnormalities. 

Examination by the aid of a 
speculum confirms the existence 
of the conic cervix and the minute 
external os. The degree of steno- 
sis of the cervical canal, and espe- 
cially of the angle of flexion, is 
difficult to estimate without pass- 
ing a sound, but this is usually 
unnecessary, since the diagnosis 
can be made from the symptoms 
and as the result of the examina- 
tion previously detailed. 

The diagnosis of pathologic 
anteflexion and stenosis must 
sometimes be based on the symp- 
toms, since the anatomic changes 
are not well marked. Given the 
symptoms of stenosis of the cer- 
vix, dysmenorrhosa, or sterility, 
even moderate alterations in form 
justify the diagnosis. 

Prognosis. — The prognosis depends upon the effectiveness of the treat- 
ment in overcoming the cervical stenosis, as well as upon the associated 
conditions. The most effective method of overcoming cervical stenosis is 
by means of dilatation and the introduction of a cervical stem. If the symp- 
toms are due to obstruction alone, the proportion of cures following this 
treatment will be large. If general ill development of the pelvic structures 
and other associated causes of dysmenorrhoea and sterility are present, the 
prognosis is doubtful. As it is difficult to make an exact differentiation in 
all cases, and impossible in some, the prognosis should always be guardedly 
16 




Fig. 256. 



Divulsion of the cervix. Rapid, with branched 
metal dilators of Goodell. 



242 



GYNECOLOGY 



favorable. . In two-thirds of carefully selected cases, however, cures may 
confidently be expected. 

Treatment. — The treatment of pathologic anteflexion should be both 
general and local. General treatment is essential, since a depressed mental 
state may lead to an exaggeration of what may be termed normal menstrual 
distress. In a large number of healthy normal nulliparae pain is present for 
a few hours at the beginning of the menstrual periods. This may be quite 
severe, but is not unbearable, and the patient may seek relief in a sim- 
ple remedy, such as the local application of heat or a hot drink. In depressed 
conditions, on the other hand, a patient may find the menstrual distress 
unendurable, improvement again following a change of air and scene or 
pleasant recreation. It is desirable, therefore, to raise the general well-being 
of the patient to the highest degree by the administration of tonics, regula- 




FiG. 257. — Dudley operation. 



Fig. 258. — Pozzi operation. 



tion of the bowels, careful oversight of the diet, and suitable outdoor exer- 
cise. If sterility is the principal indication to be met, the simple measures 
described in the treatment of sterility (Chapter XXXIII) should be tried 
before anything more definite is undertaken. Non-operative local treat- 
ment, for the purpose of developing the pelvic organs, has been advocated 
by some ; this is practically limited to the application of an aseptic intra- 
uterine electrode several times a week. In unmarried women this practice 
is to be condemned, but in the married the method may be tried although 
it is of doubtful value. After a thorough preliminary disinfection of the 
vagina and the cervix a sterile electrode is introduced into the uterus, and 
10 to 12 milliamperemeters of the galvanic current are applied for ten 
minutes. This treatment may be repeated twice a week. The negative 
pole is placed in the uterus ; the positive, on the abdominal wall. 

As a rule, if general measures fail, the patient should receive immediate 
operative treatment. The classic operation for pathologic anteflexion con- 



CHANGES IN FORM AND POSITION OF THE UTERUS 243 



sists in forcible dilatation of the cervix by means of the branched dilators of 
Goodell (Fig. 256) or the graduated sounds of Hegar. This operation must 
be performed under aseptic precautions, and as much dilatation as possible 
should be maintained for at least fifteen minutes, so that altogether about 
thirty minutes are consumed in the operation. 

Another plan to overcome the acute angle formed by the cervical canal 
is the method proposed by Dudley, which consists essentially of splitting 
the posterior lip of the cervix from the angle of flexion to the vaginal vault 
(Fig. 257). Pozzi has recently introduced a plan of operation by which a 
bilateral laceration of the cervix is made, thus imitating the effect of labor in 
removing an obstruction of the cervical canal (Fig. 258). The most satisfac- 





Figs. 259-260. — Norris drain in position (as here drawn the bulbous extremity of the stem 
reaches too far above the internal os). 

tory method for overcoming the acute angle of flexion and securing perma- 
nent enlargement of the cervical canal is the combination of thorough 
instrumental dilatation of the cervix and the insertion of a cervical 
stem, which is left in situ in the cervical canal for varying lengths of time. 
The form of stem that is most satisfactory is that devised by C. C. Norris 
(Figs. 259 and 260). This is made of hard rubber and in three sizes. The 
drains should be sterilized by boiling for fifteen minutes. After the cervix 
has been fully dilated the length of the uterine cavity should be determined, 
and care exercised in selecting the size that is suited to the case ; when the drain 
is in situ, the bulbous extremity should reach well above the internal os and 
the flanges at the butt should be closely approximated to the vaginal cervix. 
The drain is made flexible by immersion in boiling water and bent slightly 
forward ; after fixing the shape in cold water, the drain is introduced. Ex- 



244 GYNECOLOGY 

perience has shown that the uterus will expel the drain unless it is fixed in 
position, and this should always be done by attaching the flange on either 
side of the butt to the cervix by means of a silkworm-gut suture. The drain 
may be allowed to remain in situ over two or three menstrual periods. It 
can easily be removed by snipping the silkworm-gut sutures. 

The introduction of the uterine stem must be preceded by the most 
careful examination under anaesthesia and the most rigid aseptic precautions. 
If there is any indication of adnexal involvement, or if evidences of inflam- 
matory disturbances in the uterus or pelvis are present, the use of the uterine 
stem is absolutely contraindicated. Three days after the operation the 
patient may be allowed to get up, but douches and tub- and sitz-baths must 
be prohibited for a month. After the stem has been in position for a time 
the danger of infection of the uterine cavity from douche or bath water is 
lessened, but as long as the drain is in place it is well to avoid the douche 
and to limit bathing to the hot or cold shower or sponge baths. 

Another method of securing effectual dilatation of the cervix is by means 
of an instrument known as the metranoikter. This apparatus is inserted 
with the patient under anaesthesia; after dilatation of the cervix the blades 
are released, and the instrument is left in place for twenty-four hours. 
This method gives rise to considerable pain, which must be controlled by 
opiates, but good results have been reported from its use. 

RETROVERSION AND RETROFLEXION OF TFIE UTERUS 

Pathology. — Retroversion and retroflexion of the uterus are usually com- 
bined (Figs. 250 and 251). The degree of version and the degree of flexion vary 
considerably. There are three degrees of retroversion ; in the first, the axis of the 
uterus points toward the promontory of the sacrum; in the second, toward the 
hollow of the sacrum, and in the third, toward the sacrococcygeal articula- 
tion. The amount of backward flexion is usually proportionate to the 
degree of version ; in some cases the angle between the cervix and the 
fundus is obtuse, whereas in others it is acute. In exceptional cases an 
anteflexed uterus may be retroverted and in descensus. 

The most common cause of retroversio-flexion is childbirth. After labor, 
when the uterus is heavy and the ligaments are lax and overstretched, the 
uterus may fall into a posterior position, due to the fact that involution of 
the organ itself or of its ligaments is interrupted (subinvolution), that the 
dorsal position is maintained too long, that the binder is too tight, or that 
there is too early resumption of activity on the part of the woman, which 
brings increased intra-abdominal pressure to bear upon the uterus and 
forces it down into the pelvis. These causes are often coincident. In such 
cases the uterus is enlarged and softened, and the ligaments are stretched 
and elongated both anterioi J y and posteriorly. The same conditions may 
obtain after abortion, miscarriage, or premature labor. Retroversio-flexion 
may be produced gradually after labor, as the result of the loss of support 
to the pelvic structures normally afforded by the perineal floor. The me- 
chanics of displacement from this cause are fully dealt with elsewhere 



CHANGES IN FORM AND POSITION OF THE UTERUS 245 

(page 264). Chronic constipation, with habitual distention of the sigmoid 
flexure, may exert a causative influence in certain cases of retroversio-flexion. 

Retroversio-flexion may also be congenital, in which case it is usually 
accompanied by shortening of the anterior vaginal wall, poorly developed 
round ligaments, and other developmental defects. In exceptional cases 
retroversio-flexion may be acquired as the result of heavy lifting or of un- 
usual exertion, which suddenly increases the intra-abdominal pressure. 
The sudden displacement that occurs in these cases may be accompanied by 
acute pelvic distress and other manifestations that subside in the course of 
a few days without the uterus being restored to its normal position. If 
these forces are brought to bear at a time when the bladder is fully distended 
with urine, they are especially prone to cause displacement. Under such 
conditions the intra-abdominal pressure may be exerted on the anterior 
instead of on the posterior wall of the uterus, in such a way as to drive the 
organ backward (Figs. 251 and 252). Falls or blows are said to be the cause 
of certain cases of retroflexio-version. While this is possible, its occurrence 
must be very rare. In aged multiparas the uterus is often retroflexed and 
ptosed, due probably to atrophy of the fundus and of the ligaments of the 
uterus. There is often an associated relaxation of the pelvic floor. Moder- 
ate degrees of uterine displacement taking place in active reproductive life 
may become exaggerated about the time of the menopause, owing to an 
atrophy of the ligaments of the uterus and of the muscles of the pelvic floor. 
Many of the patients who at the menopause develop symptoms of pelvic 
floor relaxation and its sequelae — cystocele, rectocele, and prolapse — never 
manifest subjective symptoms of these disorders previous to that time. The 
pregnant uterus may turn backward into retroversio-flexion or pregnancy 
may occur in an already retroversio-flexed organ. 

The size of the uterus varies. In puerperal cases it is large at first, but 
after the condition has persisted for some time, the uterus may undergo a 
certain amount of shrinkage. In displacements that occur slowly following 
the puerperium and that are due to a lack of support of the pelvic diaphragm, 
no decided enlargement may be present. In traumatic cases and in nulli- 
parous women the uterus may not be larger than normal. In congenital 
retroflexion the organ is often undeveloped, and in addition to the posterior 
flexion, the fundus may be flexed to one side. Retroversio-flexion is often 
accompanied by a certain amount of torsion, so that the body of the uterus 
is rotated on its long axis to the right or the left. In retroflexio-version the 
adnexa are invariably, and, as a matter of course, lower in the pelvis than 
normal. Usually they occupy a lateral position, but in some cases one or 
both of the ovaries may lie low down in Douglas' pouch, slightly to one side 
of the median line, in close relation to the fundus. The pregnant retroversio- 
flexed uterus, if uncorrected, either slowly rights itself and rises out of the 
pelvis, or becomes incarcerated beneath the sacral promontory and is finally 
emptied by abortion. 

In persistent retroversio-flexion the pressure of the uterus upon the rectum 
and upon the ovaries and tubes may result in the formation of adhesions be- 
tween these structures. At times an acquired displacement is coincident 
with inflammation of the adnexa following septic labor, or it may even be 



246 



GYNECOLOGY 



secondary to such conditions, the displacement being due to the traction of 
adhesions between the fundus of the uterus and the peritoneal surfaces of 
Douglas' pouch. 

Other factors concerned in displacement of the uterus will be considered 
more fully when dealing with descensus or prolapsus, since retroversio- 
flexion is usually the first stage of both. 

Symptoms. — The symptoms of retroflexion consist of backache, a sense of 
weight in the pelvis, pressure about the rectum, painful and prolonged 




Fig. 261. — Sagittal section, showing uterus in extreme retroflexion, causing pres- 
sure on the rectum and traction on the bladder: constipation and vesical irritability. 



menstrual periods, and leucorrhcea (Fig. 261). In exceptional cases retroflexion 
has been the only lesion present to account for headache and various reflex symp- 
toms, such as nausea and vomiting. Bladder symptoms, such as frequent or pain- 
ful micturition, may occur, and constipation is often marked, the patient com- 
plaining of a sensation as though an obstruction to fecal evacuation existed. 
Retroversio-flexion may, when the angle of flexion is acute, pre- 
vent conception. It is also a frequent cause of miscarriage. 

Leucorrhcea usually depends upon hypertrophy of the uterine mucosa 
with hypersecretion, brought about by congestion of the pelvic blood- 
vessels and possibly as the result of some obstruction to free drainage if the 



CHANGES IN FORM AND POSITION jOF THE UTERUS 247 

angle of flexion is acute. Menorrhagia may be a prominent symptom, espe- 
cially if hypertrophy of the endometrium and subinvolution are present. 
The woman may complain of pain in the lower abdomen, on one or both 
sides, and this is especially marked if, associated with the retroflexion, there 
are adhesions that bind the uterus and the adnexa together or if one or both 
of the ovaries lie in Douglas' pouch. If but one ovary is prolapsed, the pain 
may be especially marked on that side. Under these circumstances dys- 
pareunia may be present, 

Dysmenorrhea usually persists throughout the menstrual period, the 
pain being due to the marked congestion of the uterus occurring at this 
time; gradually becoming less severe as the period subsides, occasionally 
persisting for a few days after the flow has ceased. If the angle of retro- 
flexion is acute, the menstrual pain may be of the obstructive type, i.e., most 
severe shortly before the appearance of the flow. The majority of the symp- 
toms are relieved when the patient is quiet and at rest, and most of them 
are exaggerated by the erect position, walking, or working. Vesical symp- 
toms, abdominal distress, and backache may be relieved by rest in the 
recumbent posture. 

Diagnosis. — Simple digital examination discloses the fact that the cervix 
is well forward in the vagina, and nearer than normal to the vaginal orifice. 
If the finger is pressed upward in front of the cervix, the uterine body can- 
not be felt; if it is carried back of the cervix, a rounded body (the fundus) 
can be outlined, and between it and the cervix an angle of flexion can be 
made out (Fig. 121). Bimanual examination confirms and amplifies these find- 
ings. The fundus cannot be palpated between the vaginal finger pressed upward 
on the anterior wall in front of the cervix and the abdominal fingers dipped 
down above the symphysis. If the vaginal finger is passed posteriorly and 
pressed against the fundus, and the abdominal hand is. dipped downward 
deep into the pelvis, just below the sacral promontory, the body of the 
uterus may be grasped between them (Fig. 125). 

The examination of a case of retroflexio-version of the uterus is not 
complete until it is ascertained whether the position of the organ is fixed, 
i.e., whether or not the uterus is adherent. An effort should at once be made 
to replace the organ (vide infra). This should be done with the 
utmost gentleness, especially in those cases in which the adnexa appear to 
be enlarged or fixed. 

There are some pelvic disorders that may simulate a retroversio-flexion 
of the uterus. Thus a fibroid springing from the posterior uterine wall, a 
hsematocele, a small ovarian cyst, or, indeed, any rounded adnexal tumor 
occupying the bottom of Douglas' pouch must be differentiated. The 
vaginal finger alone may be unable to detect the difference between them, 
but upon making bimanual palpation the body of the uterus can be outlined 
in front of the mass lying in Douglas' pouch and bulging the posterior 
vaginal fornix (Fig. 126). In certain obscure cases the passage of a sound may 
be required to settle the question. 

Treatment. — For the individual case of retroflexion of the uterus the 
treatment to be selected depends upon the condition of the pelvic floor, the 



248 



GYNECOLOGY 



mobility of the uterus, and the state of the adnexa. If the pelvic floor is 
sound, a pessary may be introduced to support the uterus, provided the 
latter can be replaced and maintained in a normal position and no abnor- 
malities of the adnexa are present. Even if a certain degree of relaxation of 
the pelvic floor exists, there may be enough support to retain a properly 
selected Smith pessary in correct position. If the pelvic floor is so greatly 
relaxed that a pessary cannot be kept in place ; if there are adhesions that 
prevent replacement of the uterus, or if the adnexa are diseased, operative 
treatment alone can be considered. During the active reproductive period 
a pessary should, if possible, be used. (See Selection and Preparation of 
Cases for Operation, Chapter XXXV.) 

The degree of support afforded by the perineum and the existence of 
adnexal tumors can be quickly and easily ascertained by the usual methods 
of examination. Whether or not the uterus or the adnexa are adherent is 




Fig. 262. — Replacement of retroflexio- version of 

the uterus. The cervix is grasped with a 

tenaculum. 



Fig. 263. — Replacement of retroflexio- version of 

uterus. The uterus is straightened out and the 

angle of flexion diminished by traction on the 

tenaculum. 



usually determined by the success or failure of the method used to replace 
the uterus. In simple cases, when the abdominal wall is neither fat nor 
rigid and the patient is not excessively tender, the uterus may be replaced 
by pushing up the fundus through the posterior vaginal vault, then pressing 
the cervix backward by the fingers placed in contact with the anterior sur- 
face of the cervix, at the same time engaging the fundus with the abdominal 
hand and drawing it gently forward. 

If the abdominal walls are fat or rigid ; if the patient is hypersensitive or 
easily frightened ; or if the uterus is large and heavy, this simple plan may 
fail, even though no adhesions are present. Under such circumstances the 
following method has usually been successful : The cervix is grasped with 
a double tenaculum and pulled down toward the vaginal orifice ; this 
maneuver straightens out the angle of the retroflexion, and brings the 
fundus within easy reach of the forefinger introduced into the rectum. 

Holding the cervix down, the fundus is now pressed upward by the 
rectal finger until the angle of posterior flexion is overcome, or the uterus 



CHANGES IN FORM AND POSITION OF THE UTERUS 249 

is anteflexed. With the rectal finger in position the cervix is now pushed 
backward toward the hollow of the sacrum by the attached tenaculum, and 
an attempt is made by the abdominal hand to engage the posterior surface 
of the uterus through the abdominal wall. The tenaculum is now removed 
from the cervix, but the posterior position is maintained by pressing back- 




Fig. 264. — Replacement of retroflexio- version of Fig. 265. — Replacement of retroflexio-version of uterus, 

uterus. The index finger in the rectum pushes the The cervix is now pushed back into the hollow ot the 
fundus upward, entirely correcting the retroflexion, sacrum as far as it will go. 

anteflexing the uterus and beginning anteversion. 




Fig. 266. — Replacement of retroflexio-version of Fig. 267. — Replacement of retrofiexio version of 

uterus. The tenaculum has been removed. The uterus. By further pressure on the cervix backwards 

index finger of the vaginal hand continues pressure and pull on the fundus forwards, the uterus is 

backwards on the cervix; the fingers of the abdomi- brought into slightly exaggerated anteflexion and 
nal hand engage the fundus and pull it forward. anteversion. 

ward upon the cervix with the fingers of the left hand, while with the right 
hand the efforts to engage the posterior surface of the uterine body are 
continued, and the body is drawn gently upward and forward (Figs. 
262 to 267). 

Occasionally, in order to avoid the sacral promontory, it is advisable to 
push the fundus to one side or the other of the median line with the rectal 
finger. In some cases in which this procedure is not successful the failure 



250 



GYNECOLOGY 



is due not to adhesions, but to the rigidity of the patient, or the thick- 
ness of the abdominal wall. In other cases there are slight adhesions 
that can be stretched by gradual replacement of the uterus with tampons. 
Consequently, if the effort at replacement fails, in spite of the fact that 
the history, associated symptoms, and absence of adnexal enlargement 
make adhesions or associated inflammatory conditions improbable, the 
gradual replacement method may be tried before operation is undertaken. 
This method consists of pushing the uterus bimanually to as nearly a 
normal position as possible, without using force or inflicting pain, and then 
placing the patient in the knee-chest position and packing the posterior 
vaginal vault with tampons in order to maintain, for a time, the gain that 
has been made in replacement (Fig. 268). The tampons are saturated with 

a 25 per cent, solution of glycerite of 
boroglyceride. This solution exerts a 
hygroscopic effect on and has a ten- 
dency to deplete the uterine vessels and 
to reduce the size of the uterus. In 
this way, usually after three or four 
treatments, or in the most stubborn 
cases after seven or eight, the uterus 
may be fully replaced without tension 
to its normal position, and a pessary 
can then be inserted. 

Much depends on the fitting of a pes- 
sary ; if properly fitted, it will do its work 
well and the patient will be comfortable, 
whereas under the opposite conditions it 
may fail utterly. Even though the uterus 
can easily be replaced, at the first exami- 
nation it is a good plan to use tampons 

Fig. 268.— The patient in the knee-chest position and several times before employing the pes- 
the vaginal fornix packed with tampons. 1 . ' ° 

sary. this preparatory treatment im- 
proves the condition of the mucous membrane and accustoms the patient to the 
presence of a foreign body in the vagina. 

The most suitable form of pessary for the treatment of retroversion is 
the Smith. This pessary is furnished in five sizes. The most important 
measurement to ascertain before selecting the pessary for the individual 
case is the distance between the posterior vaginal fornix and a point on the 
anterior vaginal wall a half inch within the external urinary meatus. This 
distance may be estimated by the first finger, or, if preferred, by means of a 
pair of dressing forceps and a cotton pledget. The width of the pessary, 
which is greatest at the upper curvature, is proportionate to the length, so 
that if the pessary is of the proper length, its width will be satisfactory. The 
desirable width may be determined, if necessary, by separating the blades 
of a pair of dressing forceps in the vaginal fornices, so that the blades im- 
pinge upon the lateral vaginal walls ; the amount of separation between the 
handles is then measured. After withdrawing the forceps the separation 
may be restored and the desired information obtained. 




CHANGES IN FORM AND POSITION OF THE UTERUS 251 

After selecting the size that appears to be suitable, the pessary is intro- 
duced in the oblique axis of the vagina (Figs. 269 and 270), the upper part 
being inserted as far as the cervix. With the forefinger the upper bar is then 
depressed beneath the cervix, so that the vaginal cervix lies within the 
greater curve. If the pessary is of proper size, the lower bar will be in con- 
tact with the anterior vaginal wall at a point where elevation allows it to 








Fig. 269 — Introducing a pessary. The patient in the dorsal position; the sulcus on one side 
is retracted with the first finger. The pessary is introduced in the oblique diameter. 



ride easily back of the symphysis without pinching the urethral tissues between 
it and the pelvic arch. Furthermore, it should be possible to pass the finger 
without difficulty between the lateral bars of the pessary and the vaginal 
walls, and the vaginal vault should be comfortably spanned, but not 
stretched. If the vaginal vault is put on a tension, if the patient complains 
of pain when the finger is passed between the pessary and the vaginal wall, 



252 



GYNECOLOGY 



or if, on pressing the anterior bar upward, the pessary does not ride easily 
behind the symphysis, then a smaller size must be selected. If, on the con- 
trary, the pessary is so small that it lies loosely in the vagina or does 
not fit the vaginal vault snugly and ride up well back of the cervix, or 
if, upon straining, there is a tendency for the pessary to come out, a larger 
size should be selected. 

When the vault of the vagina is low, a modification of this form of pes- 
sary, known as the Emmet, may be found more suitable than the Smith, and 
occasionally, if there is some relaxation of the vaginal outlet, the Hodge 
pessary, which has a broader lower bar, may be found more effective. 

In extreme cases of retroflexion, when the vaginal vault is very roomy 
and the pelvic floor is relaxed, a ring pessary may be the only form that can 
be used. Such cases are more properly classed under the head of descensus 

or prolapsus uteri, and the plan to be 
"adopted will be considered in connection 
with the treatment of these lesions. 

After the pessary has been introduced it 
may be advisable in some cases to place the 
patient in the knee-chest position and to re- 
tract the posterior vaginal wall; this is done 
for a double purpose — first, for inspecting 
the vaginal vault to see that the upper bar 
of the pessary is in its proper place, and 
secondly, to allow the intestines to gravitate 
out of the pelvis so that, upon resuming the 
erect or recumbent position, there will be 
Fig. 270.— Schematic diagram illustrating no knuckle of gut between the anterior sur- 

mechanics of pessarj r . The posterior vaginal r r . , 1,11111 r 

wall stretched over the upper transverse bar face of the UterUS and the bladder tO faVOr a 

of the pessary pulls the cervix upward and . „„ „„„„ ^.C ±U ~ Al ^^.\„ ~~*~,n~,4- 

backward, thus throwing the fundus forward, recurrence of the displacement. 
The pessary imha^ Before a pessary is introduced one 

must always be sure that the uterus 
is in good position. The pessary does not act by pressing on the uterus 
itself, but by stretching the posterior vaginal vault and the uterosacral 
ligaments over its upper bar. This pulls back on the cervix and throws the 
fundus forward. In cases in which there has been prolapse of the ovary. 
care must be exercised in introducing the pessary ; in such cases, following 
the introduction of the pessary, the patient should be directed to assume the 
knee-chest position daily in order to prevent incarceration of the ovary 
in Douglas' pouch. 

After the patient has been properly fitted with a pessary, she should be 
directed to return at the end of twenty-four to forty-eight hours, when an 
examination should be made so as to determine positively that the uterus is 
held in good position, and that there is no undue tension of, or pressure 
upon, the vaginal walls. After that she may be directed to return at the 
end of a month, and should be told that if, in the meantime, she experiences 
pain or discomfort, or if an unusual discharge appears, to consult a physician 
immediately, or, if this is impossible, to remove the pessary herself. As a 
rule, douches are unnecessary and contraindicated while the pessary is 




CHANGES IN FORM AND POSITION OF THE UTERUS 253 

worn. If an occasional douche is needed for purposes of cleanliness, sterile 
water or a very weak solution of lysol (i : 200) may be used. 

At the end of a month or six weeks the pessary should be removed for 
twenty-four hours, when, if the displacement has recurred, the uterus should 
be returned to its proper position and the pessary reinserted. This plan 
should be repeated every month or six weeks. In recent cases, following 




Fig. 271. — Alexander's operation. (Kelly and Xoble, Gynecology and Abdominal Surgery. W. B. Saunders Co.) 



labor or miscarriage, the uterus will, as a rule, remain in place at the end of 
three or four months. In some cases a longer time is required for the 
ligaments to undergo involution and hold the uterus securely. If a cure is 
not accomplished at the end of six months, the patient may choose between 
wearing the pessary indefinitely or submitting to an operation. (See Selec- 
tion of Cases for Operation, Chapter XXXV.) 

The treatment of a pregnant retroversio-flexed uterus consists of re- 



254 



GYNECOLOGY 



placement and the introduction of a pessary. If the case is seen early and 
there is no immediate danger of incarceration, the assumption of the knee- 
chest position twice daily may be sufficient. The uterus may gradually 
right itself, after which a pessary should be introduced. If this plan fails, 
or if incarceration is imminent, an attempt should be made to replace the 
uterus at one sitting by the usual methods, except that the cervix should 
not be caught with a tenaculum. It may be necessary to use general anaes- 
thesia before success can be achieved. 

The operative treatment of retroversio-flexion of the uterus consists of 
shortening some of the ligaments of the uterus or attaching them or the 
uterus itself by sutures directly to a neighboring organ or to the abdominal 




median line 



H.^ecKer 



Fig. 272. — Ventrosuspension. (Kelly and Noble, Gynecology and Abdominal 
Surgery. W. B. Saunders Co.) 

parietes. One of the earliest methods of treatment, and one that is still 
applicable in young women or in uncomplicated cases of retroversio-flexion 
in women of all classes, is shortening of the round ligaments as they lie 
within the inguinal canal. This is commonly known as Alexander's opera- 
tion (Fig. 271). The scope of this operation is limited, since in young 
women surgical measures for the correction of retroflexion are not fre- 
quently employed ; moreover, when operative treatment of this condition is 
required, the retroversio-flexion is often accompanied by some intra- 
abdominal condition that needs correction ; or the patient may declare that 
if she is to undergo an operation, the appendix should be removed at the 
same time. 

One of the chief advantages of the Alexander operation, when it was 



CHANGES IN FORM AND POSITION OF THE UTERUS 255 




Fig. 273. j -Coffey's operation, bteos i and 2. 




Fig. 274. — Coffey's operation. Steps 3 and 4. After step 4 the peritoneum of the anterior leaflets 
of the broad ligament is drawn over the suture line of the round ligament and attached to the uterus 

by a continuous suture. 



256 



GYNECOLOGY 




Fig. 275. — Webster-Baldy operation. Steps* i and 2. 




Fig. 276. — Webster-Baldy operation. Step 3. 



CHANGES IN FORM AND POSITION OF THE UTERUS 257 

first employed, was due to the fact that the peritoneal cavity was either not 
at all or only very little invaded. At the present time, with the perfection 
of aseptic detail, there is but little risk from a peritoneal opening, and if the 
patient objects to the scar of a median incision, the skin may be incised 
transversely just above the symphysis. 




Fig. 277- -Simpson operation. The skin and fat are retracted and freed 
from the f iseia of the rectus muscles on both sides of the lower extremity 
of the abdominal incision slightly below the level of the internal ring. The 
fascia is incited for half an inch about one inch from the median border of the 
fascia on each side, the fingers inside the incision giving support. 

The intraperitoneal operations for the cure of retroflexion are numerous. 
A number of years ago ventrosuspension of the uterus, or the attachment 
of the fundus to the anterior abdominal wall, was the method usually 
adopted, and when the operation was correctly performed, the immediate 
results were excellent (Fig. 2J2). The opportunities for later sequelae of a 
serious nature are numerous enough to abandon this form of uterine sus- 
pension during the reproductive period. 
17 



258 GYNECOLOGY 

The unfortunate and grave sequela? of ventrosuspension were the conse- 
quence of a too firm attachment of the uterus to the abdominal parietes. 
This was due to the fact that the operator included the fascia of the abdominal 
wall in his suture, or, as the result of suppuration of the incision or from a 
peritonitis, the attachment became permanent and extensive. The ideal 
result of ventrosuspension properly performed is the production of a new 
ligament running from the fundus of the uterus to the anterior abdominal 
wall, and made up largely of peritoneal and subperitoneal cellular tissue, 
and a few muscle-fibers that have been gradually pulled away from the 
peritoneal surface of the anterior abdominal wall, to which the uterus was 
attached. It can readily be seen how this band may, to a certain extent, be 
a menace to the intestines, and in some cases intestinal obstruction has occurred. 
Many forms of operation for the shortening of the round ligaments have 
been suggested. The original Mann operation consisted simply in redupli- 
cating the ligaments upon themselves and suturing the reduplications to- 
gether. The three forms of round ligament operations that seem best 
adapted to the majority of cases are: First, the plan elaborated by Coftey 
(Figs. 273 and 274), which consists of reduplicating and attaching the 
round ligaments to the anterior surface of the uterus; secondly, the type 
of operation de\~ised by Simpson and used with great satisfaction by many 
surgeons, which consists of attaching the round ligaments to the abdominal 

parietes ; each ligament in turn is caught and 
pulled through a slit in the peritoneum close 
Cm\ to the internal ring, and then guided between 

the peritoneum and the anterior abdominal 
wall to the rectus muscle ; the fascia of the 
rectus muscle is perforated, and the ligament 
^ is drawn through and attached by means of 

q sutures (Figs. 277-280) ; thirdly, the method 

^ suggested by AYebster and Baldy, of drawing 
$ the round ligaments through the broad liga- 
ment to the posterior surface of the uterus 
and attaching them at this point (Figs. 275 
and 276), an operation that is particularly 
. j suited to those cases in which the ovaries are 

Fig. 278. — Simpson operation. The liga- eSOeciallv low. 

ment is pulled up and a small snip made «t»i 1 r r c 

in the peritoneum of the anterior surface 1 he real test Ol all tvpeS Ot Operation for COr- 

of the broad ligament directlv beneath the . . 

traction suture. rectmg retroflexion ot the uterus is the errect the 

operation has on pregnancy and labor, and 
whether the displacement is likely tc recur during the puerperium. Fixation of 
the uterus may prevent the physiologic enlargement incident to pregnancy, and 
lead to abortion or overstretching and thinning of certain parts of the 
uterus. Fixation of the uterus has resulted in grave dystocia, requiring 
craniotomy or Cesarean section, or serious forceps operations. During the 
child-bearing period the uterus should never be fixed, but always suspended. 
When, however, the patient has passed the child-bearing age, it is advisable 




CHANGES IN FORM AND POSITION OF THE UTERUS 259 




Fig. 279. — Simpson operation. A specially curved needle is now- 
passed through the fascial cut, between the muscle bundles to the 
peritoneum, beneath this to the internal ring, then under the peri- 
toneum of the anterior leaflet of the broad ligament and through 
the peritoneal cut. The traction suture ends are then threaded 
through the eye of the needle, which is withdrawn. 




Fig. 280. — Simpson operation. The round ligaments are sutured to the under surface of the 
fascia by three interrupted sutures of fine linen or catgut. These also close the fascial incision. 



260 GYNECOLOGY 

to furnish permanent support, and the uterus may then be fixed to the anterior 
abdominal wall. This is accomplished by attaching the fundus of the uterus 
to the fascia of the abdominal wall (Figs. 287 and 288), in the manner to be de- 
scribed later, under the Treatment of Descensus and Prolapse, page 268. 

The uterus may also be suspended or fixed through a vaginal incision 
that invades the abdominal cavity through the uterovesical peritoneum. 
This plan is regarded as eminently satisfactory by those gynecologists who 
have had much experience with it, but its scope is limited, since the tubes 
and ovaries are not so well exposed to surgical treatment, and lesions of the 
vermiform appendix or other intra-abdominal affections that need correc- 
tion cannot be treated. 

Alexander's Operation. — The technic detailed by Noble should be fol- 
lowed. An incision about two and one-half inches in length is made from 
the spine of the pubes, a little above but parallel with a line between the 
spine of the pubes and the anterior superior spine of the ilium. The 
incision is carried through the skin, subcutaneous fat, and superficial fascia 
down to the external oblique. Each bleeding point is caught and ligated — 
this is a cardinal point in the successful performance of the operation, for if 
it is neglected the tissues become blood-stained and identification of the 
round ligament is rendered difficult. When the external oblique is exposed, 
the superimposed fat is detached throughout the length of the incision, and 
on each side of its median line for about 1 cm. The external ring is now 
located either by sight or by touch, and the external oblique muscle is 
divided in the direction of its fibers about as far as the internal ring. The 
borders of the divided external oblique are now retracted, and the internal 
oblique muscle is separated from Poupart's ligament by blunt dissection. 
This completely exposes the inguinal canal. The round ligament and the 
ilio-inguinal nerve are identified, and the nerve is drawn to one side. When 
the ligament is seen, it should be caught with a blunt hook and drawn out 
until the reflection of the peritoneum is seen. As the ligament is drawn out 
the reflection of the peritoneum is detached by means of blunt dissection. 
The amount of shortening can be determined by palpating the lower surface 
of the abdominal wall just above the pubes ; with experience the operator 
will be able to estimate this correctly by muscular sense. The peritoneum 
is opened in from 30 to 50 per cent, of the cases ; when this occurs the adnexa 
may be palpated through the opening. After the ligaments have been suffi- 
ciently shortened, the excess is cut away and the ligament is stitched to the 
fibers of the internal oblique and Poupart's ligament, the external oblique 
fascia being united over them as in the Bassini operation for the radical cure 
of inguinal hernia (Fig. 271 ) . If the peritoneum is opened, it should, of course, 
be sutured with fine catgut. If there is difficulty in locating the round liga- 
ment, the best guide is the internal ring. The operation is applicable only 
when disease of the adnexa and adhesions can positively be excluded. Its 
field of application is, therefore, quite limited. 

Ventrosuspension. — A low paramedian cceliotomy incision is made to the 
right of the median line. The lower end of the incision should reach the 
symphysis pubis. The peritoneum to the left of the incision in the lower 
angle of the wound is caught with artery forceps and pulled out of the 



CHANGES IN FORM AND POSITION OF THE UTERUS 261 

incision and to the right. A needle armed with celloidin thread is now 
passed through the exposed peritoneum at the extreme lower end of the 
incision, the point of entrance being two centimeters from the edge of 
the peritoneum. In its sweep the needle embraces the adjacent preperi- 
toneal connective tissue and a few fibers of the rectus muscle and emerges 
about a centimeter to the left of its point of entrance. The needle is then 
passed through the fundus of the uterus, slightly posterior to a line between 
the uterine insertion of the tubes, picking up tissue one centimeter in depth 
and breadth. A second suture is passed in exactly the same manner as the 
first, but a centimeter above it (Fig. 272). After both sutures have been 
placed they are tied with care, a finger in the abdominal cavity preventing 
the coils of intestine from slipping between the fundus and the inner sur- 
face of the abdominal wall. 

In this operation none of the fixed constituents of the abdominal wall 
are included in the suspension suture, so that subsequent to the operation a 
gradual separation between the fundus of the uterus and the anterior abdom- 
inal wall takes place, and a new ligament is formed by traction from the 
parietal peritoneum and the few fibers of the rectus muscle embraced by the 
sutures. The technic described is similar to that employed in the method of 
McMonagle. It fixes the fundus directly in the median line, but places the 
point of attachment a couple of centimeters away from the line of peritoneal 
closure, so that in the event of suppuration of the incision — which very rarely 
occurs — the inflammatory process does not reach the suspension sutures. 

Ventral Fixation. — The object of ventral fixation is totally different 
from that of ventrosuspension. By ventral fixation the fundus of the uterus 
is permanently attached to the fixed structures of the anterior abdominal 
wall. This operation is never justifiable unless future conception is impos- 
sible. It consists in making a low median coeliotomy incision, pulling the 
uterus upward into the lower angle of the incision, and attaching the peri- 
toneum to the periphery of the fundus, thus making it extraperitoneal. The 
rectus muscle on either side of the incision is now separated from the under 
surface of the fascia and the fundus is attached directly to the fascia by two 
or more sutures of No. 1 forty-day chromic catgut (Figs. 287 and 288). 

Coffey's Operation. — Coffey has devised an operation (Figs. 27$ and 
274) in which he utilizes the round ligament and a portion of the broad 
ligament. In performing this operation a low median coeliotomy incision is 
made. A point on the round ligament is selected the approximation of which 
to the uterine cornu, the uterus being held in proper position, makes the 
ligament between the internal ring and the point of approximation taut. 
The apex of the loop thus formed is then attached to the anterior surface of 
the uterus, about an inch below the insertion of the round ligament. At the 
point originally selected the ligament is then drawn over to the cornu of the 
uterus, and attached immediately below the insertion of the round ligament. 
The peritoneum of the broad ligaments between these two fixed points is 
united to the peritoneum of the anterior uterine wall by a running catgut 
suture. The same plan is carried out upon the opposite side. 

Simpson Operation. — This is performed as follows: A low median 



262 GYNECOLOGY 

coeliotomy incision is made. A point on the round ligament is selected the 
approximation of which to the anterior abdominal wall holds the fundus of 
the uterus in good position. The round ligament at this point is surrounded 
by a strand of catgut (traction loop). Sufficient traction is made upon the 
loop to expose the anterior face of the broad ligament, the peritoneum of 
which is snipped just below the point of traction. The lower outer surface of the 
rectus fascia is bared for an inch to one side of the incision. A longitudinal cut 
one centimeter in length is made through the fascia, two centimeters or slightly 
more from the edge of the fascia, on a level with the internal abdominal ring, ex- 
posing the rectus muscle (Fig. 2jj). A long and especially curved blunt pedicle 
needle is passed through the fascial opening and the fibers of the rectus until it is 
felt immediately beneath the peritoneum ; it is then turned outward and 
made to traverse the extraperitoneal space between it and the abdominal 
wall and the anterior surface of the broad ligament, until it can be pushed 
through the opening made in the anterior leaflet of the latter, just below the 
point selected on the round ligament (Fig. 278). The ends of the catgut 
loop are passed through the eye of the needle and the needle is with- 
drawn. Traction on the catgut draws the round ligament under the peri- 
toneum across the anterior face of the broad ligament to the internal ring, 
beneath the peritoneum of the anterior abdominal wall, to the outer border 
of the rectus muscle, through the muscle, and to the fascial incision. The 
loop of the round ligament presenting in the fascial incision is sutured 
to the under surface of the fascia with three interrupted sutures of linen 
thread. The sutures do not surround but perforate the ligament peripheral 
to the central artery. The sutures are so disposed as to close the fascial 
incision at the same time that they attach the ligament. 

Webster-Baldy Operation. — Webster and Baldy have devised a plan 
of operation whereby the round ligament is drawn through the broad 
ligament below the utero-ovarian ligament, and attached to the posterior 
surface of the uterus (Figs. 275 and 276). This operation is of value prin- 
cipally in cases associated with marked prolapse of the ovary. A point on 
the round ligament of one side is selected which, when approximated to the 
cornu of the uterus, will make the round ligament taut from the internal 
ring to the uterine cornu. At the junction of the parallel limbs thus formed, 
a strand of catgut (traction loop) is passed around but not through the 
ligament. With the forefinger beneath the utero-ovarian ligament, a clear 
space in the ligament is now found, and the ligament perforated from 
behind forward with a curved blunt artery forceps. The points of 
the instrument are slightly separated, so as to stretch the opening, and 
the ends of the catgut strand are caught in the grasp of the forceps. The round 
ligament is now drawn through the opening in the broad ligament to the pos- 
terior surface of the uterus. The same procedure is carried out on the 
opposite side. The round ligament is sutured to the posterior uterine sur- 
face, about an inch below the fundus, with interrupted linen sutures. 
When the ligaments are greatly relaxed, the loops of the two round liga- 
ments may be united in the median line, or in some cases they may even be 



CHANGES IN FORM AND POSITION OF THE UTERUS 263 

overlapped. Great care should be exercised to avoid puncturing the round 
ligament vessels ; the openings in the broad ligaments should be large enough 
to obviate constriction of the round ligament. The ligaments should not be 
drawn tight. The linen sutures should not surround the ligaments, but 
should be made to perforate them to the peripheral side of the central artery. 
All these precautions have as their object the preservation of the circulation 
in the round ligament. 

Shortening of the Uterosacral Ligaments. — Shortening of the uterosacral 
ligaments may be performed in conjunction with other operations of uterine 
suspension when the ligaments appear unduly relaxed, as is indicated by the 
fact that the cervix itself seems particularly low in the pelvis ; in other 
words, when, in addition to retroversion or flexion, there is well-marked 
descensus. After the round ligament operation is completed and any 
necessary pelvic treatment has been carried out. the patient should be 
placed in an exaggerated Trendelenburg position, and the intestines well 
packed out of the pelvis. The fundus of the uterus is held forward with a 
long, narrow retractor. A mattress linen suture is passed on each side from 
the posterior surface of the uterus, below the position of the internal os. 
through the uterosacral ligament, about 2-3 cm. from the uterus. When tied, this 
suture will usually give the necessary amount of shortening of the ligament, but 
it must be adapted to the individual case. One or more additional mattress 
sutures are then passed to secure approximation of the reduplicated part of 
the ligament and the posterior surface of the uterus below the position of the 
internal os (Fig. 289). 

DESCENSUS AND PROLAPSE OF THE UTERUS 

Etiology, Pathology. — The terms descensus and prolapse of the uterus im- 
ply a descent or a dropping of the uterus below its normal level in the pelvis. De- 
scensus frequently complicates retroversio-flexion of the uterus. Indeed, the first 
stage of descensus is, as a rule, preceded by a turning backward of the 
uterine axis (retroversion), and this is combined, as usual, with back- 
ward flexion (retroflexion). The causes of descensus are the same in kind 
as those that produce retroversio-flexion, but greater in degree. The in- 
competency of the uterine ligaments, the pelvic floor, and the abdominal 
Avail is more marked than in retroversio-flexion. 

The forces that normally hold the uterus at its proper level may well be 
illustrated by the two simple experiments in physics noted by Penrose. The 
abdominopelvic cavity may be compared to a glass cylinder filled with 
water, and closed above and below by the finger and thumb. Normally, 
the bottom of the abdominopelvic cavity is the pelvic floor, the top is the 
diaphragm, and the sides are made up of the anterior, posterior, and 
lateral abdominal and pelvic parietes (Fig. 281). 

If the thumb is removed from the bottom of the glass tube, the water 
does not run out, but is held in the cylinder by atmospheric pressure and by 
virtue of the unyielding walls and the finger securely closing the top. 
Similarly in the abdominopelvic cavity (Fig. 282), when the perineal floor is 
injured, if the parietes of the abdomen retain their strength, the retentive 



264 



GYNECOLOGY 



power of the abdomen tends to prevent a descensus of the pelvic and the 
abdominal viscera. If, however, the anterior abdominal parietes are relaxed 
and weak, instead of being strong and unyielding, a similar effect is exerted 
upon the pelvic viscera as if a section of the glass cylinder were replaced 
by rubber-dam which would yield to atmospheric pressure — some of the 
water would then be lost. 

The influence of relaxation of the pelvic floor on the position of the uterus 
may also be illustrated in the following way: Given a vessel filled with 
water at rest, a molecule of water some distance from the bottom of the 
vessel is pressed upon equally in all directions — that is, the pressure beneath 
is equal to the weight of the column of water above. The pressure from 




Fig. 281. — The pressure upon the uterus from 
all sides is equal; it has been compared to the 
equilibrium of a molecule of water in a vessel; 
the sides of the vessel are the pelvic and 
abdominal walls. The floor of the vessel is the 
pelvic floor. The uterine ligaments act simply 
as guy ropes. 



Fig. 282. — The pelvic foor is torn and the 
uterus is now a part of the floor of the pelvis; 
the intra-abdominal pressure on the uterus 
must be met by the ligamentous and other 
attachments of the uterus. The anterior ab- 
dominal wall is relaxed and the retentive 
power of the abdomen is impaired. 



below is maintained partly by the strength of the bottom of the vessel. The 
latter may be represented by the pelvic floor, the intervening water by the 
vagina, the cellular tissue surrounding it, and the bases of the broad liga- 
ments, and the molecule of water in equilibrium by the uterus. 

When the pelvic floor is relaxed, the introitus vaginse gapes, the vaginal 
walls are not in contact, and the support to the cervix is greatly impaired. 
Instead of resting on the pelvic floor, the cervix really becomes a part of the 
pelvic floor (Fig. 282). Intra-abdominal pressure acting upon the uterus 
and tending to force it downward must then be met largely by the strength 
of the uterine ligaments. Every act of the woman that increases intra- 
abdominal pressure tends to augment the strain upon the pelvic structures, 
so that they slowly give way and the uterus descends through the vagina. 
Another factor in the descent of the uterus is the pull upon the cervix by 



CHANGES IN FORM AND POSITION OF THE UTERUS 265 

the unsupported vaginal walls. As a result of relaxation of the pelvic floor, 
before there is any descent of the uterus, a cystocele or a rectocele may be 
produced. Attempts at defecation and urination give rise to a protrusion of 
the anterior or the posterior vaginal walls, or both, as the case may be, and 
this exerts a downward pull upon the cervix. 

The predisposing cause of descensus and prolapse may be congenital 
deficiencies in the pelvic and uterine supporting structures. This explains 
the complete prolapse in nulliparous women which occasionally occurs in 
those who habitually work hard or do heavy lifting. 

Descent or prolapse of the uterus is frequently associated with viscero- 




FiG. 283. — Schematic outline, showing various steps in the development 

of procidentia uteri. The uterus turns backward as it begins to 

descend; downward displacement of the uterus becomes more marked 

after the axis of the uterus lies in the axis of the vagina. 



ptosis. The latter may be coincident, depending upon the same factors that 
produced the prolapse, or it may precede the condition and be an evidence 
of a general lack of tone in the ligamentous structures formed by the peri- 
toneal reflexions in the abdominal wall and in the pelvic diaphragm. The 
uterus has been said to undergo acute prolapse in a previously normal 
woman as the result of sudden and unusually violent increase of intra- 
abdominal pressure, as by lifting a heavy weight. Such an occurrence must 
be exceedingly rare. In apparent cases of this description it may be taken 
for granted that there was a preceding slow but progressive descent of the 
uterus, with overstretching of its supports, which at the time of the prolapse 
suddenly gave way and produced pain and other localizing symptoms. 



266 



GYNECOLOGY 



Descensus of the uterus progresses slowly (Fig. 283). As the uterus 
traverses the vagina the vaginal walls become inverted. When the cervix has 
fallen so low that it presents at the vaginal introitus, the condition is usu- 
ally known as prolapse (Fig. 284). 

The degree of uterine prolapse is best described by mentioning the posi- 
tion of the cervix (Fig. 283) — that is to say, prolapse of the uterus with the 







Fig. 284. — -Prolapse of the uterus; cervix presenting at the vaginal orifice. Vesical and rectal diverticula. 



cervix at the vaginal entrance, prolapse of the uterus with the cervix an 
inch outside of the vaginal orifice, etc. When the entire uterus is displaced 
beyond the introitus, the condition is known as procidentia. 

Preceding or accompanying the descensus and prolapse there are usually 
pouchings of the anterior vaginal wall with the bladder, and of the posterior 
vaginal wall with the rectum. These may be regarded as vesical and rectal 
diverticula. In rare cases, as the vagina becomes inverted, it becomes sepa- 
rated from the contiguous vesical and rectal walls, so that there may be 



CHANGES IN FORM AND POSITION OF THE UTERUS 267 

complete prolapse of the uterus and total inversion of the vagina, without 
much participation of either the bladder or the rectum. 

Although the cervix may project beyond the vulva in some cases of pro- 
lapse, this does not necessarily signify that the body of the uterus is pro- 




1 



• 




Fig. 285. — Complete prolapse of the uterus with bladder diverticulum. 



portionately displaced. On the contrary, in numerous instances the cervix seems 
particularly prone to descend, whereas the body and the fundus remain more 
or less fixed. This results in a thinning and an overstretching of the supra- 
vaginal cervix ; when this occurs the condition is known as a partial prolapse of 
the uterus with supravaginal elongation and thinning of the cervix. 



268 GYNECOLOGY 

Accompanying descensus or prolapse, any of the lesions of the cervix due 
to labor may be present. The cervix seems to show an especial tendency to 
become hypertrophied. This may be the result of mechanical irritation inci- 
dent to the displacement, or the hypertrophy may have been primary and 
in itself a contributing factor. 

In cases of total prolapse of the uterus, or procidentia, the projecting 
mass often forms a mechanical hindrance to walking. At those points where 
the pressure is greatest and most continuous the mucous membrane is likely 
to undergo ulceration. If a vesical diverticulum is present, there may be a 
constant residuum of urine in the bladder, which finally causes a low-grade 
cystitis. If a rectal diverticulum exists, hemorrhoids are prone to follow as 
the result of the difficulty in defecation thus occasioned. 

Symptoms. — The symptoms of descensus or prolapsus of the uterus de- 
pend upon the degree of displacement and upon the accompanying lesions. 
The most characteristic complaint is of a bearing-down sensation in the 
lower abdomen, with a feeling of loss of support, backache, and pain in the 
thighs, exaggerated by exertion, and relieved by the recumbent posture. 
With these symptoms there may be associated : frequency and profuseness 
of the menstrual flow from pelvic congestion; leucorrhcea from inflammation of 
the vaginal or the cervical mucosa and overgrowth of the endometrial 
glands ; and vesical and rectal irritability from vesical and rectal diverticula. 

Diagnosis. — The diagnosis of the milder grades of descensus is made 
upon the findings of digital examination — i.e., the cervix and the entire 
uterus are found at a lower level than normal. The vagina is usually short- 
ened, and the axis of the cervix corresponds directly with that of the vagina, 
the body of the uterus, as a rule, being in retroversion. The uterus may, 
however, be anteflexed, particularly when the round ligaments are strong 
and the cause of the descensus is chiefly due to a pull upon the cervix 
from below. 

In extreme degrees of descensus and of prolapse, the diagnosis can be 
made simply by inspection ; upon directing the woman to bear down, the 
cervix appears either close to or at the vulvar orifice, or the entire, uterus 
may protrude from the vaginal introitus. 

When the patient has been in bed for a time, the degree of descent may 
not be apparent at once, nor be rendered so immediately by the patient's 
efforts. Under such circumstances, if the cervix is caught with a tenaculum 
and gently drawn downward, the desired information will be secured. 

The presence of a rectal diverticulum can easily be determined by mak- 
ing a digital examination of the rectum ; the presence of bladder diverticulum 
can be determined by the introduction of a sound. It is always advisable to 
ascertain exactly, by means of bimanual palpation, the position of the 
fundus of the uterus, so as to determine whether or not one is dealing with a 
complete or a partial prolapse. 

Treatment. — The treatment of descensus of the uterus and prolapse de- 
pends upon the amount of downward displacement, the age of the patient, 
and the associated conditions. During the reproductive period the lesser 
degrees of descensus may be treated in the manner described for retroversio- 



CHANGES IN FORM AND POSITION OF THE UTERUS 269 



flexion, with which they are almost invariably associated. In the more 
marked degrees of descensus and prolapse, a Smith or a Hodge pessary may 
be maintained in position only with difficulty, on account of the relaxed con- 
dition of the perineum. Although one of the types of ring pessary will hold 
the uterus up, it may not maintain it in anteposition, so that the treatment 
will be unsatisfactory. Furthermore, ring pessaries, with the exception of 
the simple hard-rubber forms, interfere more or less with coitus, and may be 
objectionable from that standpoint. 

With the exception, therefore, of the lesser degrees, in which the uterus 
can be supported and maintained in normal position by a Smith or Hodge 
pessary, operation is the treatment of choice. In aged women and in those 
who present some contrain- 
dication to operation, non- 
operative treatment must of 
necessity be adopted. 

The mechanics of support 
by a ring pessary differ from 
the action of the Smith or the 
Hodge pessaries (Fig. 286). 
The latter not only support the 
uterus in position, but they 
throw the fundus forward. 
The ring pessary finds its 
support in the walls of the 
vagina, the muscles of the 
perineal floor, and the rami 
of the pubes. If the diameter 
of the vaginal fornices ex- 
ceeds that of the vaginal 
introitus, a hard-rubber ring 
pessary may be used; it 
should be of such a size as to 
keep the vaginal fornices 
spanned, the tissues sur- 
rounding the vaginal outlet helping to 
vaginal introitus is very much smaller, 




Fig. 286. — The principle of support of a Menge pessary. The knob 
or rudder keeps the rim with its greatest diameter transverse to the 
axis of the vagina: in such relation as indicated at A, it requires a 
canal of larger caliber to permit its escape than when it turns edge- 
wise as at B ; in this position it can pass through a canal of consider- 
ably smaller caliber, C. 



hold the pessary in place. If the 
it may be impossible to introduce 
a hard-rubber ring pessary that will span the vaginal fornices. Under such 
circumstances a soft-rubber pessary that can be compressed at the time of 
introduction may be selected. 

When it is necessary to use a ring pessary that is more than two inches 
in diameter in a case of descensus or prolapse with cystocele, the hard- 
rubber simple ring type is not always satisfactory, for the anterior vaginal 
wall shows a tendency to prolapse through the ring. Under these circum- 
stances the disk form may be used with advantage. The broad surface of 
the disk forms a satisfactory support for the anterior vaginal wall and base 
of the bladder. 



270 



GYNECOLOGY 



When the diameter of the outlet is greater than that of the vaginal 
fornices, and the ring does not secure sufficient support from the vaginal 
Avails and pelvic floor, the difficulty may be overcome by utilizing the sup- 
port afforded by the bony arch of the symphysis and rami of the pubes. This 
can be a factor only Avhere the plane of the pessary is maintained more or 
less at right angles to the axis of the vagina — in other words, when it pre- 
sents its surface, and not its edge, at the vaginal outlet. The ordinary ring 
pessary will not maintain the desired position, but Menge has devised a 
form that overcomes this difficulty. This has, in addition to the ring, an 
attachable stem that lies in the axis of the vagina, and therefore keeps the 
plane of the pessary at right angles. The Menge pessary has been a very 
valuable addition to the non-operative treatment of descensus and prolapse. 
It has rendered nearly every case amenable to this plan of treatment, so 
that pessaries of the Goddard type may be regarded as almost obsolete. 





Fig. 287. — Extraperitoneal fixation of fundus. Step 1. Fig. 288. 



-Extraperitoneal fixation of fundus. 
Step 2. 



The general rules of treatment by the pessary are the same here as in cases 
of retroposition. In aged patients, particularly, it is advisable not to allow 
the device to remain in place for more than a month at a time. 

The operative treatment of descensus and prolapse combines the opera- 
tions necessary for restoring the integrity of the pelvic floor, and those that 
suspend or fix the uterus at the normal or slightly above the normal level. 
Usually, in the child-bearing woman, some form of cystopexy and peri- 
neorrhaphy must be performed, in conjunction with Simpson's, Baldy's, or 
Coffey's operation. It is in these cases particularly that shortening of the 
uterosacral ligaments, when combined with the other operations, may be 
serviceable. A fixation operation is never selected unless the woman has 
passed the menopause or has been artificially rendered sterile. Plastic work 
in prolapse is, as a rule, more extensive than in descensus, and as prolapse 
occurs more frequently in older women, fixation operations are oftener 
desirable. The choice of the particular type of fixation operation for the 
individual case depends upon the associated conditions. Vaginal fixation 
may be the operation of choice if, by reason of obesity or the expressed wish 



CHANGES IN FORM AND POSITION OF THE UTERUS 271 

of the patient, an abdominal incision is objectionable. Interposition of the 
uterus between the bladder and anterior vaginal wall is especially indicated 
when a cystocele is a prominent feature of the case, when the uterus is normal in 
size, and when the cervix does not prolapse beyond the vaginal introitus. 

Supravaginal hysterectomy and fixation of the stump to the abdominal 
wall are particularly suitable when relaxation of the uterine ligaments is 
extreme and the fundus can be drawn out of the incision to such an extent 
that the stump of the cervix, after removal of the body of the uterus, will 
just reach the anterior abdominal parietes. Supravaginal hysterectomy and 
suspension of the stump by the round ligaments may be selected when 






Fig. 289. — Shortening of uterosacral ligaments. 

relaxation of the uterine ligaments is not extreme, but the body of the 
uterus is enlarged and heavy and it is desirable to remove it. 

Simple extraperitoneal fixation of the fundus uteri may be selected when, 
upon pulling up the uterus as far as it will go, the fundus just about reaches 
the anterior abdominal wall, the body of the uterus is not enlarged, and there 
is no indication for hysterectomy (Figs. 287 and 288). 

In operations for descensus and prolapse, the treatment of the cervix de- 
serves particular mention. During the reproductive period high amputation 
should be avoided. Trachelorrhaphy is the procedure of choice, and should 
be selected unless the cervix is so greatly hypertrophied or there is such a 
distribution of Nabothian cysts that nothing short of amputation will re- 
store the cervix to a satisfactory condition. In women past the child- 
bearing period high amputation of the cervix is usually advisable, since it 



272 GYNECOLOGY 

lessens the weight of the uterus and removes the vaginal portion, which, if 
let alone, might predispose to a recurrence of descensus, guiding the uterus 
down through the vagina just as the olive tip of a bougie guides it through 
the urethra. After high amputation the vaginal vault is concave, the tissues 
are more or less fixed to the bases of the broad ligaments, and are less dis- 
posed to downward displacement. An exception to this may be noted in the 
interposition operation. High operation does not lend itself to the technical 
execution of the latter, and if the condition of the cervix is such that amputa- 
tion is necessary, some other form of uterine fixation should be selected. 

As a preliminary step in any case that is to be subjected to operation, and in 
non-operative cases for palliative purposes, the prolapsed uterus may be restored 
to its normal position and held there by vaginal tampons of gauze or cotton. 
Either of these materials should be applied in the form of a long strip, first 
being disposed in a circular manner about the cervix until the whole vaginal 
vault is filled, pressure being then exerted laterally upon the vaginal fornices. 
Below this the packing may be loose. A dusting powder (boric acid or zinc 
stearate) or an ointment (petrolatum, zinc ointment, etc.) may be applied 
to the gauze or cotton. This tamponade forms a large spheric mass that 
embraces the cervix and finds support upon the lateral walls of the pelvis 
and upon the pubic rami. Such a tampon must not be left in place for more 
than twenty-four hours at a time. 

In case of ulceration of the vaginal mucosa in prolapse of the uterus, the 
organ should be replaced in the manner described, and kept there for several 
weeks before operation, the ulcer being cleansed and touched with silver 
nitrate (2 per cent.) daily before the tamponade is reintroduced. Within a 
week or two this treatment will result in healing of the ulcerations, and the 
mucous membrane of the vagina and the submucous areolar tissues will be 
less cedematous and in a much more favorable condition for operation. 

Vaginal Fixation. — Vaginal fixation of the uterus is an operation that 
has a very limited field of application. The operation is especially use- 
ful when there is a serious contraindication to an abdominal operation, such 
as excessive fat, or if the patient herself wishes to avoid an abdominal in- 
cision. It should be reserved for women who have passed the child-bearing 
period. If used in others, it must be in conjunction with an operation to 
render the individual sterile. In performing this operation a midline incision 
is made through the anterior vaginal wall, from a point one centimeter 
posterior to the external urinary meatus to the point where the vaginal wall 
joins the anterior lip of the cervix. Here the midline incision is crossed by a 
transverse incision that divides the vaginal wall along the line of its attach- 
ment to the cervix. The bladder is separated from the anterior vaginal wall 
and from the anterior surface of the uterus, and pushed up until a point is 
reached on the anterior uterine wall more than half-way between the in- 
ternal os and the fundus (Fig. 220). It is always advisable to open the peri- 
toneum. The anterior surface of the uterus is now sutured to the anterior vag- 
inal wall, the bladder being pushed up out of the way and the fixation sutures 
so disposed as to close the peritoneal opening. 

Watkins' Operation. — Interposition of the Uterus between the Bladder 
and the Vagina. — Interposition of the uterus is indicated chiefly in descensus 



CHANGES IN FORM AND POSITION OF THE UTERUS 273 

or minor degrees of prolapse with particularly marked cystocele. The operation 
is not advisable in cases of complete prolapse, since in older to make it effec- 
tive some support must be left in the uterosacral ligaments and the tissues 
surrounding the cervix and the vaginal vault. (Sec page 221.) The anterior sur- 
face of the uterus and the base of the bladder are exposed by means of the T- 
shaped incision described under the head of vaginal fixation. The bladder is 
separated from the anterior vaginal wall and the cervix by blunt dissection and 
pushed upward. The vesico-uterine fold of peritoneum is divided and the 
uterovesical pouch is opened. The pelvis is then carefully explored with 
the finger, in order to determine the presence of adhesions or of intrapelvic 
disease. If the fundus is small and no adnexal complications exist, it is 
drawn through the opening in the uterovesical pouch, and the anterior edge 
of the peritoneum is united to the posterior surface of the uterus below the 
fundus somewhat above the position of the internal os. The excess of the 
vaginal wall is now excised from either side of the median line, and united 
over the anterior surface of the uterus, the latter being fixed in its new posi- 
tion by several interrupted catgut sutures. This operation must be supple- 
mented by some form of perineorrhaphy (Figs. 222 and 223). 

Fixation of the Uterine Stump after Supravaginal Hysterectomy. — The 
operation of supravaginal hysterectomy is carried out in the usual manner, 
without attaching the round ligaments to the cervix, up to the point of peri- 
tonealization of the raw surfaces. Instead of covering in the cervical stump 
with peritoneum, it is left bare, transfixed with two chromic catgut (No. 2) 
sutures, and drawn up into the lower end of the abdominal incision. The 
peritoneum of the lower angle of the incision is then united to the anterior 
surface of the cervix along the peritoneal reflection. The peritoneum on 
either side is now sutured over the ovarian and round-ligament stumps and 
the cut surface of the broad ligament. The peritoneum of the abdominal 
incision is then attached to the lateral and posterior surfaces of the cervix 
and closed above this point. Each end of the sutures transfixing the cervix 
is now carried through the fascia of the abdominal wall on its corresponding 
side, the under surface of the fascia being exposed by blunt dissection. The 
fascia is brought together with catgut in the usual manner, and the cervical 
sutures are tied. The raw surface of the cervical stump is thus brought into 
contact with the under surface of the fascia, and a broad and secure area of 
fixation is the result. The principles underlying this operation are the same 
as those of extraperitoneal fixation of the fundus (Figs. 287 and 288). 

Ante-position, Latero-position, Retro-position, Elevatio Uteri, and Tor- 
sion. — These variations from the normal in the position of the uterus are of 
less importance than those previously discussed. They, practically never 
produce symptoms other than those characteristic of the conditions with 
which they are associated. 

The uterus may be pushed forward against the symphysis {ante- position), 
to one side toward the wall of the pelvis (latero-position), and backward into 
the hollow of the sacrum (retro-position) by a tumor that crowds the uterus 
out of its way or by adhesions that, by contraction, draw the uterus out of 
its normal position. 

The uterus may also be elevated (elevatio uteri) considerably above its 
18 



274 GYNECOLOGY 

usual position by a tumor developing from the cervix or by adhesions form- 
ing between the fundus and the abdominal viscera. The uterus- may be 
elevated by an abdominal tumor of uterine origin, or displaced downward 
by an ascites or pseudomyxoma peritonei. 

The uterus may be twisted (torsio uteri) by the torsion of tumors at- 
tached to it or by an enlarged uterus twisting on the cervix as a pedicle. 
Latero-position of moderate degree and torsion are likewise to a certain 
extent physiologic, e.g., the normal rotation to the right of the pregnant 
uterus, and have no pathologic significance. 

The treatment of all these abnormalities must, of course, be directed to- 
ward the primary source of the trouble, i.e., tumors must be removed and 
adhesions broken up or divided. In very rare cases it may be advisable to 
attempt to correct the latero-flexion of an ill-developed uterus. 

INVERSION OF THE UTERUS 

Etiology and Pathology. — Inversion of the uterus, or turning of the 
uterus inside out, usually takes place at the end of labor, when the uterine 
muscle is relaxed and the lower uterine segment and the cervix are widely 
dilated. The improper management of the third stage of labor is usually 
responsible for this condition. Too forcible applications of Crede's method, 
pulling upon the umbilical cord, or faulty methods of manual extraction of 
an adherent placenta may be the exciting cause. 

If, in employing Crede's method, the fundus is too vigorously com- 
pressed and depressed, the organ may be driven down through the lower 
uterine segment and cervix, the walls everting as it passes. If the placenta 
is firmly attached to the uterine wall at the fundus, traction on the cord 
may cause inversion of the fundus. If the hand is introduced into the 
uterus to detach an adherent placenta, and, having accomplished this, the 
hand grasping the placenta is immediately and forcibly withdrawn, it may 
act like a piston in a syringe and draw the organ inside out. Forceps deliv- 
ery of a fcetus with an exceptionally short cord has been said to be a cause 
of acute inversion. 

Inversion of the uterus other than puerperal may occur as a complication 
of intra-uterine tumors that become pedunculated and are extruded through 
the cervix by uterine contraction. If the pedicle of the neoplasm is broad 
and attached to the fundus, inversion may take place. 

Symptoms. — Acute inversion is an alarming condition, and is usually 
accompanied by serious hemorrhage and shock. It may take place at 
the end of the second stage of labor, but it usually complicates the manipula- 
tions attending delivery of the placenta. At the moment of occurrence the 
patient complains of severe pain, the hemorrhage is excessive, and a state of 
shock rapidly develops. Hemorrhage and shock are less severe if the 
placenta is still attached to the uterine wall. A globular pyriform mass 
protrudes from the vulva or presents at the vulvar orifice. If the placenta is 
still attached, the condition is apparent. If the placenta has been delivered, 
the condition must be differentiated from extrusion of a submucous peduncu- 
lated fibroid. In the former, examination of the fundus reveals a funnel- 
shaped depression ; in the latter, the rounded fundus can be felt in its normal 



CHANGES IN FORM AND POSITION OF THE UTERUS 275 

position. The mortality of acute inversion is 30 per cent. Inversion occur- 
ring slowly, as from the traction of a fibroid, or when of puerperal origin and 
allowed to remain unreduced, is the form with which we are most concerned 
here. The symptoms consist of irregular hemorrhage, menorrhagia. and 
leucorrhcea. Upon examination a pear-shaped tumor is found projecting from 
the vaginal vault. The surface is bright red. the growth bleeds readily, and 
the pedicle is surrounded by the rim of the cervix. 

Bimanual examination shows the normal contour of the fundus to be 
missing, and in its place there is a cup-shaped depression that can readily be 
distinguished by a digital examination per rectum. A sound introduced 
along the pedicle of the tumor, and between it and the rim of the cervix, soon 
meets with the resistance of the inverted cervical tissue. The condition 
bears some resemblance to a uterine polyp or to a submucous pedunculated 
fibroid tumor. The principal differential and diagnostic signs are the fol- 
lowing : The fact that the surface of the tumor is covered with endo- 
metrium, in which the tubal orifices may be distinguished ; obliteration of 
the uterine cavity ; and the cup-shaped depression at the fundus. 

Treatment. — In acute puerperal inversion, if the patient is in an extreme 
state of shock and the surroundings are unfavorable, simple tamponade and 
general supportive treatment should first be undertaken ; under opposite 
circumstances immediate replacement should be attempted. The woman 
should be placed in the Trendelenburg position, and an effort be made to 
push the inverted fundus up through the cervix. This procedure will be 
favored by grasping the entire fundus with the hand, compressing it as much 
as possible, and then making an effort to push it past the cervix. If the 
"effort is successful, as the fundus is restored to its normal position, the 
inversion is reduced. When the inversion has persisted for some time and 
partial involution has occurred, replacement is considerably more difficult. 
Division of the cervical ring is almost invariably required, but even when 
this is performed replacement is often impracticable. In most cases of long 
standing and in women past the age of thirty-live hysterectomy is the pro- 
cedure of choice. 

At times the inverted portion, owing to interference with its blood 
supply, becomes necrotic. Under such circumstances the gangrenous part 
may be removed with the cautery knife, and after the stump becomes cov- 
ered with healthy granulations, the remains of the uterus may be removed by 
vaginal or abdominal hysterectomy. 

BIBLIOGRAPHY 

Alexander. W. : " A New Method of Treating Inveterate and Troublesome Displacements 
of the Uterus.'' Med. Times and Gazette. 1882. i. 327. 

Axspach, B. M. : "Inversion of the Uterus, the Treatment in Cases Complicated by Ne- 
crosis of the Inverted Part." Amer. Medicine, viii. Xo. 22, November 26, 1904. 

Baldv, J. M. : "A Method of Preventing Vaginal Prolapse Following Abdominal Hyster- 
ectomy."' Am. Jour. Obst., 1857. xxxv, 81 : Ibid. : " Retrodisplacements of the Uterus 
and Their Treatment." X. Y. Med. Jour., 1903, lxxviii, 167: Ibid.: ''Prolapse of the 
Uterus.'' Trans. Amer. Gyn. Soc, 191 2, xxxvii, 385. 

Ballextvxe. J. \Y.. axd Thomson, J. : " Congenital Prolapsus Uteri."' Amer. Jour. Obst.. 
1897. xxxv. 161. 

Bovf.f. J. W. : "The Surgical Treatment of the Uterosacral Ligaments Through the 
Vagina in Retroversion of the Uterus." J. A. M. A.. 1902, xxxix, 12; Ibid.: "Opera- 



276 GYNECOLOGY 

tions on the Uterosacral Ligaments in the Treatment of Retroversion of the Uterus." 
Am. Gyn., 1902, i, 3?. 

Brickner. S. M. : " Results of the Dudley Operation." Surg., Gyn. and Obst., 191 1, xiii. 510. 

Coffey, R. C. : " Surgical Treatment of Displacements of the Uterus.'" Denver Med. 
Times, 1904-5, xxiv. 339. 362 : Ibid. : " The Principles on Which the Success of the 
Surgical Treatment of Retrodisplacements of the Uterus Depends."' Surg., Gvn. and 
Obst.. 1908, vii, 383-408. 

Dudley, E. C. : '* A Plastic Operation Designed to Straighten Out the Antefiexed Uterus." 
Amer. Jour. Obst.. 1891. xxiv, 142. 

Ferguson. A. H. : " Preliminary Report of Anterior Transplantation of the Round Liga- 
ments for Displacements of the Uterus."' J. A. M. A.. November 18, 1899. xxxiii, 1275. 

Gilliam, T. : " Round-Ligament Ventrosuspension of the Uterus." Amer. Jour. Obst., 
1900. xli. Xo 3. 

Holden. F. C. : " Chief Factors in Failure of Operations for Retrodisplacement of the 
Uterus." Trans. Sec. O. G. and A. S., A. M. A. 1914, 279. 

Hutchixs : " Anteposed L~terus and Pelvic Svmptoms." Trans. Sec. O. G. and A. S., 
A. M. A.. 1916. 63. 

Kelly, H. A. : '" Hysterorrhaphy." Am. J. Obst., 1S87. xx, 33 : Ibid. : " Suspension of the 
L'terus." T. A. M. A., 1895, xxv. 1079. 

Martin: Der Haft-Apparat der Weiblichen Genitalien. Berlin. 191 1. 

Montgomery, E. E. : " Modern Method of Treatment of Prolapsus Uteri." Trans. Amer. 
Gyn. Soc, 1912. xxxvii. 3-6. 

Xoble, C. H. : '" Suspensio Uteri With Reference to Its Influence Upon Pregnancy and 
Labor.'" Trans. Amer. Gyn. Soc. 1896, xxi. 247 ; Ibid. : " Mechanical Principles In- 
volved in the Cause of Backward and Downward Displacements of the Uterus."' Trans. 
Amer. Gyn. Soc, 1914, xxxix, 23S. 

Olshausen, R. : " L'eber ventrale Operation bei Prolapsus und Retroversio Uteri.'" Cent. 
f. Gynak.. October. 1886. Xo. 43. 698. 

Pozzi, S. : " On the Surgical Treatment of a Most Frequent Cause of Dysmenorrhea and 
Sterility in Women."' Surg.. Gyn. and Obst.. 1909, ix. iii. 

Reynolds, *E. : "Anteflexion of the Cervix and Spasm of the Uterine Ligaments in Rela- 
tion to Retroversion, Dysmenorrhcea and Sterility." Surg., Gyn. and Obst., 191 1, 
xiii. 17: Ibid.: " Forward Fixation of the Cervix a Predisposing Cause of Some Retro- 
deviations of Uterus. Operation for Its Release.*' Surg.. Gyn. and Obst., 1914, xix. 588. 

Schultze : The Pathology and Treatment of Displacements of the Uterus. X. Y.. 1888. 

Simpson. F. F. : "Intra-abdominal but Retroperitoneal Fixation of the Round Ligaments 
for Posterior Uterine Displacements." Trans. Southern Surg, and Gyn. Soc, 1902, 
xv. 223. 

Somers. G. B.. and Blaisdell. F. E. : '" The Anatomy and Surgical Utility- of Sacro- 
uterine Ligaments."' T. A. M. A., 1913, lxi, 1247. No. 14. 

Tandler and Halban : Anatomie u. Aetiologie der Genitalprolapse beim Weibe. Wien 
u. Leipzig. 1907. 

Watkins, T. T. : "The Treatment of Cystocele and L'terine Prolapse .After the Meno- 
pause." Am. Gyn. and Obst. Jour.. 1899, xv. 420 : Ibid. : " Treatment of Cases of Exten- 
sive Cystocele and L'terine Prolapse."' Surg., Gyn. and Obst., 1506. ii, 659 ; Ibid. : " Treat- 
ment of Cystocele and L'terine Prolapse During the Child-bearing Period." Trans. 
Amer. Gyn. Soc, 1917. xiii. S94- 

Webster. T. C. : "A Satisfactory Operation for Certain Cases of Retroversion of the 
L'terus." J. A. M. A.. 1901. xxxvii. 913. 

Winter, G. : Zur Pathologie des Prolapses. Fest. f . C Ruge, 1896, 22. 






CHAPTER XVI 
DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 

Endometritis. — Endometritis, or an inflammation of the mucous mem- 
brane lining the body of the uterus, may be acute or chronic. 

Acute endometritis is the result of infection of the endometrium by the 
gonococcus during the course of gonorrhceal disease, or of infection by the 
staphylococcus, streptococcus, or other pus-producing organisms following 
abortion, premature labor, or intra-uterine manipulations or operation. 
Acute gonorrhceal endometritis is a sequel of gonorrhceal cervicitis, and usu- 
ally develops about the time of the menstrual period ; or it may follow mis- 
carriage, labor, or local applications to the cervix. It is marked at times 
by sudden cessation of the menstrual flow, a profuse discharge of purulent 
matter from the cervix, pyrexia, pain in the lower abdomen, and some of the 
symptoms of pelvic peritonitis. It is. indeed, very difficult to distinguish 
the latter clinically from acute gonorrhceal endometritis. Acute gonorrhceal 
endometritis frequently extends speedily into the tubes on either side, and 
thence to the pelvic peritoneum. 

Whether or not it does so, if the conservative measures presently to be 
outlined are adopted, the inflammatory process gradually subsides, although 
the disease does not tend to undergo a complete cure, but is likely to become 
subacute or chronic in type and most persistent. The fever, pain, etc.. dis- 
appear, the uterine discharge becomes less purulent in character, and may 
finally contain only a small amount of pus. In the chronic stage, as a 
result of the previous acute inflammation, the endometrium often shows hyper- 
trophy of the glands, so that there are hypersecretion and a considerable 
amount of leucorrhceal discharge. 

The infection remains, and the gonococcus, after invading the depths of 
the endometrial glands, lies dormant, not giving rise to any active symp- 
toms. Certain forms of irritation may, however, light up the infection when 
transplanted into fresh soil, and an active inflammation may be set up. 

Acute endometritis following labor, abortion, or instrumentation, and 
caused by the ordinary pyogenic organisms, is usually accompanied by a 
chill or chilly sensations, elevation of temperature, and increased pulse- 
rate. The pain may be very moderate, and the discharge is often insignifi- 
cant, unless placental or decidual tissue remains within the uterus. The 
patient may be greatly prostrated as the result of absorption of toxic prod- 
ucts with localizing symptoms appearing. Such an infection of the endo- 
metrium usually precedes a cellulitis, pelvic peritonitis, or ovarian abscess, 
the bacteria penetrating the wall of the uterus directly from the original 
nidus of infection, and reaching the periuterine tissues by way of 
the lymphatics. 

An acute endometritis of this variety may undergo complete and spon- 
taneous cure if the resistance of the patient is sufficiently strong to over- 

277 



278 GYNECOLOGY 

come the toxins elaborated by the infecting organisms and inhibit their 
growth. Following such an acute endometritis there may be no permanent 
alteration in the structure of the endometrium, and, indeed, this is the rule 
unless the infection has involved the uterine wall and the surrounding 
organs and tissues. Even in the latter event after the infection is overcome 
or localized the parts may return to the normal. 

Diagnosis. — The diagnosis of endometritis is frequently indicated by the 
history and symptoms. There is considerable tenderness in the lower abdo- 
men, with rigidity of the abdominal wall and a tendency to distention. The 
uterus is enlarged and may be soft and tender. The cervix is often more 
patulous than normal. As a rule, there is a profuse purulent discharge, 
although in cases of pure streptococcus infection there may be none what- 
ever. (See Acute Pelvic Peritonitis, Chapter XXI.) 1 

Treatment. — The treatment of all forms of acute endometritis is prac- 
tically the same. Only those post-abortal or puerperal cases, in which there 
are marked evidences of retention within the uterus of placental or decidual 
tissue (profuse putrid discharge), lie within the operative sphere. In such 
cases it may be advisable gently to dilate the cervix and then, with a 
placental forceps or a dull curette, make sure that tissue remnants and detritus 
have been cleared away. The remainder of the treatment is purely non- 
operative. The patient should be kept quietly in bed, and an ice-bag should 
be applied to the lower abdomen. The bowels should be moved by 
enemas. The patient should be supported by nutritious food and stimulants, 
according to the requirements of the case. This will be more fully dealt 
with in a succeeding chapter. 

Chronic Endometritis. — Chronic endometritis is a sequel of acute endo- 
metritis. Not infrequently what is regarded as a chronic endometritis is 
not a true inflammatory process, but rather a hypertrophy of the endo- 
metrium. 2 Such a hypertrophy occurring without a previous acute inflam- 
mation may be due to a chronic congestion of the uterine mucous mem- 
brane brought about by displacements of the uterus, constipation, chronic 

1 The gonococcus may be identified by the staining of smears made from the discharge. 
Other organisms may be identified by intrauterine cultures. It is impossible to distinguish 
clinically between acute endometritis and the first stages of the following conditions, with 
which it is often combined : acute salpingitis, oophoritis, cellulitis, pelvic peritonitis, 
and thrombophlebitis. 

2 For the diagnosis of chronic endometritis Frankl believes that such symptoms as con- 
nective-tissue proliferation, increased vascularity, the occurrence of perivascular fibro- 
blasts, etc., as suggested by Albrecht. are perhaps of theoretic interest, but are too difficult 
of demonstration to be useful for practical purposes. Diffuse infiltration of the stroma 
by round cells, or numerous groups of these in the neighborhood of blood-vessels or 
lymph-spaces, are of considerable significance, provided the specimen was not taken 
during the late premenstruum or during menstruation, at which times Frank! justly de- 
clares such diffuse or scattered round-cell infiltration is entirely physiologic. Frankl, 
in common with Hitchmann and Adler, believes that the most reliable sign of chronic 
endometritis consists in the presence of considerable numbers of plasma cells. An oc- 
casional cell of this type may be present, Frankl asserts, in normal tissue but when they 
are found in any number, chronic inflammation may be diagnosed with certainty. Although 
it is true that in certain types of inflammation round-cell infiltration predominates, whereas 
in others, particularly in the gonorrhoeal form, plasma cells are especially prominent, Frrinkel 
does not believe that the distinction occurs with sufficient regularity to be available for the 
differential diagnosis of gonorrhoea, as has been claimed by Schriddae and others. 



DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 279 

pelvic stasis, and any other cause that increases continuously the blood- 
supply of the uterine mucosa. Before it was recognized that the endo- 
metrium underwent a regular metamorphosis every month, many curetted 
fragments of endometrium were believed to be significant of chronic glandu- 
lar endometritis or a glandular hypertrophy, when it is probable that the 
condition was but one of the normal monthly variations taking place in 
the structure of the mucous membrane. There is no doubt, however, that 
forms of chronic endometritis and of glandular hypertrophy occur. A com- 
mon form of chronic endometritis is the result of an uncured infection by 
the gonococcus. The acute symptoms subside, but the organisms still re- 
main in the deeper layers of the mucous membrane, giving rise to a per- 
sistent low-grade irritation of the endometrium and the presence of a leucor- 
rhceal discharge. Tuberculous and syphilitic endometritis are dealt with in 
the chapters on Tuberculosis and on Syphilis (XXX, XXXI). 

As has previously been noted, instances are seen in which the endo- 
metrium is thickened and the glands are increased in number and in size, 
and yet no actual infection has ever occurred ; this is a true glandular hyper- 
trophy. At times the thickening of the mucosa appears in isolated areas 
and the mucosa presents a polypoid appearance — known as polypoid hyper- 
trophy. In some cases, especially in old women, in addition to the over- 
growth of the endometrium and the hypertrophy of the glands, many of the 
glands become cystic and distended with their secretion ; this condition is 
known as glandular hypertrophy with cystic degeneration. Ail these forms 
have been described as varieties of chronic endometritis, and have been 
given specific titles, as, e.g., glandular endometritis, cystic glandular endo- 
metritis, polypoid endometritis, and fungous endometritis, the descriptive 
adjective in each case indicating the gross anatomic findings. 

True chronic endometritis, as well as the hypertrophies just mentioned, 
very rarely exists alone as the sole and individual lesion of the generative 
tract. In other words, endometrial lesions of this type are usually combined 
with other disorders, such as inflammatory diseases of the adnexa, displace- 
ment of the uterus, etc. 

Symptoms. — The only symptoms that are directly attributable to chronic 
endometritis are leucorrhcea, menorrhagia, and dysmenorrhea. Other symp- 
toms believed to be due to chronic endometritis are usually the result of 
associated conditions, such as chronic pelvic congestion, displacement of the 
uterus, lacerations of the cervix, or chronic inflammatory diseases of the 
adnexa. Chronic endometritis alone may prevent conception or be provo- 
cative of abortion. 

Diagnosis. — The diagnosis may be suspected if there is a persistent 
uterine leucorrhcea that does not show the thick, tenacious character of a 
cervical leucorrhcea, and menorrhagia, without any gross lesion in the pelvis. 
The diagnosis can be confirmed only by performing thorough curettement of 
the uterus (Fig. 290) and making a careful examination of the uterine scrapings. 

Treatment. — The treatment of suspected endometritis that is not accom- 
panied by any other pelvic disorder consists in measures to stimulate the 
pelvic circulation, deplete the engorged blood-vessels, and promote free 



280 



GYNECOLOGY 



drainage of the endometrial cavity. The treatment is practically the same 
as that described under Chronic Pelvic Inflammation (Chapter XXI). So. far as 
any direct treatment of the endometrium itself is concerned, the only measure 
worth considering is curettement, followed by the application of the tincture 
of iodine or of phenol to the entire uterine interior. The use of local appli- 
cations to the endometrium is attended with considerable danger, and can- 
not be carried out unless the patient is anaesthetized and the os is fully dilated. 
It should never be attempted without the most elaborate aseptic preparation. 

Polyps of the Endometrium. — An endometrial polyp is a growth that 
springs from the endometrium, being at first, in a measure, a localized hyper- 
trophy of the endometrium. After the hypertrophy has attained a certain 
size it takes on the proportion of a distinct new formation, and may then be 
regarded as a polyp. The tumor is composed of glands and stroma, just as 
the endometrium itself, and the surface is covered by low columnar cells. 
It varies in size from a tumor no larger than the end of the finger to one 





Fig. 290. — Diagnostic curettage (pages 121, 289 and 345). 

that entirely fills the uterine cavity. The growth often corresponds in shape 
to that of the uterine interior, the polyp forming a more or less complete 
cast. The tumor is usually pedunculated, but small growths may be sessile. 
Various forms of degeneration may occur : The stroma may undergo myxo- 
matous degeneration ; cedema and infiltration with blood are frequent ; the 
surface epithelium may be eroded and the glands become cystic. If actual 
infection has taken place, the stroma is infiltrated with small round cells or 
polymorphonuclear leucocytes. Malignant degeneration of the epithelial 
constituents is not uncommon ; carcinoma of the endometrium at times 
begins in a polyp. If, by reason of uterine contraction and efforts to expel 
the growth, the pedicle of the tumor becomes attenuated, necrotic changes 
from strangulation are prone to occur. The uterus may succeed in expelling 
the growth, and a natural cure thus be afforded. 

The symptoms of a polyp are, first, a slightly increased discharge, which 
may escape the observation of the patient, to be followed later by menor- 
rhagia and metrorrhagia. Bleeding between the periods occurs only after 



DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 281 

degeneration or circulatory changes in the tumor have resulted in actual 
rupture of some of its blood-vessels. In the event of necrosis, the discharge 
becomes putrid. 

The diagnosis of endometrial polyp may readily be made in those cases 
in which the growth protrudes through the cervix. In these instances in- 
spection alone reveals a soft, globular or flattened, tongue-like growth pro- 
jecting from the cervix. It is often impossible to distinguish such a tumor 




Thickened endometrium 
infiltrated with blood 



Fig. 291. — Chronic arteriosclerosis or fibrosis uteri: thick hypertrophied 
uterus; chronic metritis (after Donald); persistent hemorrhage from such 
uteri has been attributed to sclerosis of the uterine vessels or myofibrosis. 

from a cervical polyp, but the treatment is, fortunately, the same for both. 
A polyp may be suspected in cases of menorrhagia or metrorrhagia in which 
the patients present no enlargement or irregularity of the uterus or other 
gross pelvic lesion. 

A positive diagnosis may be only possible after dilatation and curette- 
ment of the uterine cavity. 

Treatment. — As the symptoms presented by polyp always resemble 
those due to cancer, a positive or a complete diagnosis should be withheld 
until the growth is removed by avulsion or curettement and subjected to 



282 



GYNECOLOGY 



expert microscopic examination. Avulsion of a polyp should always be 
followed by curettement unless the tumor projects from the cervix and is 
infected or necrotic. Under such circumstances the operation may be postponed 

until a later date, when all indica- 
tions of infection, etc., have 
disappeared. 

Acute Metritis. — Acute metritis is 
usually preceded by acute endo- 
metritis, and is most often due to in- 
fection by the staphylococcus and the 
streptococcus, or by some of the cus- 
tomary pus-producing organisms pres- 
ent in acute puerperal septic conditions. 
The symptoms of acute metritis 
closely resemble those of an acute 
septic endometritis, being, however, 
slightly greater in intensity and ac- 
companied probably by a moderate 
enlargement of the uterus itself. It is 
quite impossible, but fortunately un- 
necessary, to differentiate acute 
metritis from acute endometritis, 
acute cellulitis, and, in fact, from most 
of the pelvic inflammatory lesions fol- 
lowing post-partal or post-abortal 
infections. 

The treatment is essentially the 
same as that of acute endometritis. 
Acute metritis is much more likely 
than the latter to be followed by cellu- 
litis or inflammation of the ovary or 
of the pelvic peritoneum, and is at 
times complicated by destruction of 
foci of tissue in the uterine wall and 
the formation of intramural abscesses. 
In some of the most marked cases in 
which this abscess formation occurs it 
may be advisable ultimately to per- 
form hysterectomy, but in the acute 
stages of the disease this operation 
must not be considered. (See Post- 
abortal and Post-partal Pelvic Peri- 
tonitis, Chapter XXI.) 
Chronic Metritis. — Chronic metritis is a sequel of acute metritis, or it 
may take the form of a slowly produced and subacute affection closely akin 
to subinvolution. It usually occurs in multiparas and is marked by hyper- 
trophy or overgrowth of the uterus. 3 The organ is considerably larger than 

3 Whitehouse has recently shown that syphilis may be a factor of importance in the 
etiology of chronic metritis. 




H 



yrtfrfAS 



Fig. 292. — Diagrammatic scheme to illustrate vas- 
cular channels of uterine wall and endometrium: 
tortuous vessels of the vascular layer (X) ; centrip- 
etal vessels of the submucosa (F); subepithelial 
capillary plexus (Z); arteries (A); veins (V); 
Glands (G). 



DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 283 

normal, and may be remarkably increased in density (Fig. 291). The actual 
change in the structure of the uterus that accounts for the enlargement of 
the uterus has been the subject of considerable discussion, but the general 
opinion is that there is an increase of the fibrous at the expense of the mus- 
cular tissue. The production of chronic metritis is closely associated with 








s\v. 



~4 



5.5 V. 



5.5. 



Fig. 293. — Section of wall of nulliparous uterus (Weigert's stain ). Observe the finely branching elas- 

tica, especially marked in the stratum subserosum (5. S.)\ note the general centripetal direction of 

the fibers. Stratum supra-vasculare (S. S. V.); outer limits of stratum vasculare (S. T'.). 

the process of involution of the uterus, and especially the involution of its 
vascular supply (Figs. 292 to 297). The vessels of the uterus, which have 
become greatly hypertrophied during pregnancy, normally degenerate, be- 
come obliterated, and undergo absorption during the puerperium. When, 




Fig. 294. — Section of wall of muciparous uterus (Weigert's stain). Observe the clumping of the elastica, the 
curling and coarseness of the fibrils. Subserous layer (S. S.) ; Supravascular layer (S. S. V.) 

for some reason, this process is imperfect, a certain amount of permanent 
enlargement takes place that predisposes the patient to chronic metritis. 

Symptoms. — The symptoms of chronic metritis consist in a serous leucor- 
rhceal discharge, menorrhagia. at times metrorrhagia, a feeling of heaviness 
or dull pain in the lower abdomen, and backache, especially when the woman 
is on her feet. 



284 



GYNECOLOGY 



Diagnosis. — On examination the uterus is found to be considerably en- 
larged and harder than normal. Occasionally it is in a state of retroversion, 
and at other times it is in anteversion, the fundus lying a little farther for- 
ward than normal, the axis of flexion between the body and the cervix being 
straightened out so that the cervix lies further backward. The cervix is 
often hypertrophied ; the os may be slightly dilated, and Nabothian cysts 
are not rarely present. The adnexa may show nothing abnormal, although 
not infrequently light adhesions or simple cysts of one or of both ovaries 
may be present. 

Treatment. — Measures that deplete the pelvic circulation should be 




Fig. 295. — Group of arteries from vascular layer of multiparous uterus (Weigert's stain). The internal 
elastic lamina (i. e. 1.) appears well preserved; there is no tendency to clumping of the elastic fibers in 
the media (M.). The adventitia (A.) presents solid clumps of elastic tissue. Periarterial degeneration. 

adopted immediately. These include hot douches, scarification of the cer- 
vix, saline laxatives, and enemas, and ergot, hydrastis, and digitalis by the mouth 
(see Menorrhagia, page 583). The use of boroglyceride tampons may also 
give good results. If these measures are not speedily effective, it is a good 
plan to do a curettement of the uterus for exploratory purposes, as well as to 
deplete the uterus through the resulting hemorrhage, stimulate the uterus 
to contraction, and remove the hypertrophied endometrium. This may be 
combined, when feasible, with a high amputation of the cervix. Such a 
course will often result in permanent cure. If the symptoms persist, it will 
be necessary to perform supravaginal or vaginal hysterectomy. The re- 
markable results that have been achieved in late years by the use of radium 



DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 285 

make this form of treatment a distinct and hopeful addition to the therapy of 
metritis and its often intractable hemorrhage (see Radium and Rontgen Ray 
Therapy, Chapter XL). 

Subinvolution of the Uterus. — When the normal regression of the uterus 
from a puerperal to a resting or non-pregnant state is inhibited and the 
organ remains enlarged, softened, and congested, subinvolution is said to 
exist. The muscular and fibrous tissue elements of the uterine wall remain 
to a certain degree hypertrophied, and the myometrium becomes succulent 
from infiltration with blood and serum. 

Sclerosis and obliteration of the blood-vessels have not progressed to the 
usual extent, so that they remain more numerous and of larger caliber than 
in the non-pregnant state. Subinvolution of the uterus is usually accom- 




FiG. 296. — Small artery of vascular layer of multiparous uterus (Weigert's stain) : 
the internal elastic lamina (i. e. 1.) can still be seen in part well preserved; 
the adventitia (.4) and part of the media (M) are represented by a solid mass of 
elastic tissue. To the left is a sagittal section through the degenerated coats of 
the same vessels (5. S.); arterial obliteration. 



panied by certain other abnormalities that account for or occur pari passu 
with it ; these are : Retention within the uterus of ovular or placental re- 
mains ; posterior or downward displacement of the uterus, and chronic low- 
grade infection of the uterine wall, adnexa, or pelvic cellular tissue. 

The symptoms of subinvolution consist of hemorrhage (metrorrhagia or 
menorrhagia), backache, a feeling of weight and pressure in the lower abdo- 
men, leucorrhoea, and possibly vesical or rectal disturbances. If a portion of the 
placenta or ovum remains within the uterus, there may be a more or less 
constant foul-smelling and bloody discharge. The entire uterus is uniformly 
enlarged and softened, and the organ is often displaced backward or down- 
ward. The os uteri is patulous. The cervix may exhibit a recent laceration, 
and the cervical tissue is soft. 

Treatment. — The contributory causes should be removed ; thus the 
uterus should be replaced and held in position by means of a pessary, and 



286 



GYNECOLOGY 



placental or decidual remnants should be removed from the uterine cavity 
with the aid of the curette or the placental forceps. The cedematous condition 
of the uterine muscle should be relieved by the use of boroglyceride tam- 
pons and hot douches. Fecal stasis should be prevented by the administra- 
tion of a saline laxative daily, followed by a simple enema. The pelvic and 
uterine circulation should be improved by the exhibition of a pill of ergotin, 
digitalis, strychnine, and hydrastis ,( see Menorrhagia, page 583). Later, 
in order to complete the cure, amputation or repair of lacerated or hyper- 
trophied cervical lips may be undertaken. 




Fig. 297. — Large vein from vascular layer of multioarous uterus (Weigert's stain); the inner 

coat (i.e.) shews no change; the outer coat (o.c.) is represented by large deposits of elastic 

tissue in clumps; perivenous degeneration. 



Hyperinvolution of the uterus is much less frequent than subinvolution. 
This is a condition of uterine atrophy following pregnancy, and results from 
a regression of the constituents of the uterus beyond the normal, so that the 
various components of the uterine wall are reduced in number and in size. 
The most frequent cause of the disorder is prolonged lactation. It is asso- 
ciated with anaemia and malnutrition in poorly-fed and overworked mothers. 
It may occur in the course of certain constitutional diseases, such as dia- 
betes and tuberculosis. Septic infection during the puerperium may predis- 
pose to an atrophy of the uterus. A hyperinvolution of the uterus is found 
in the aged. 



DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 287 

The symptoms are those of asthenia and anaemia, the particular symptom that 
may direct attention to the pelvis is amenorrhcea or scanty menstruation. 

It has been claimed that electric (galvanic) stimulation is of value in 
the treatment of lactation atrophy of the uterus, but in the permanent form 
produced by septic infection it is of little benefit. 

Perforation of the Uterus. — Perforation of the uterus is a not uncom- 
mon accident attending the introduction of the uterine sound, dilatation of 
the cervix, and curettement. The injury may be inflicted as the instrument is 
being introduced through the cervix, and then involves the lower uterine 
segment ; or it may take place after the instrument has reached the fundus. 
The accident is recognized by the lack of the normal resistance to the pas- 
sage of the instrument exerted by the fundus, the identification of the end of 
the instrument, by suprapubic palpation, free in the abdominal cavity, and 
by an excess of hemorrhage. 

When the accident occurs in the course of an aseptic operation, in experi- 
enced hands it will usually be detected at once, and there will be no further 
mutilation of the uterus by repeated passage of the instrument and no irri- 
gation of the uterus will be practised. A gauze drain may be placed in the 
uterus for twenty-four hours and the accident regarded with equanimity. 

The serious perforations of the uterus are those inflicted by unpractised 
or unclean operators. They often occur in connection with attempts at 
criminal abortion. The perforation made by the curette is not recognized, and 
the instrument is repeatedly plunged through the wound, or a placental 
forceps may be opened and shut after it has been introduced into the abdom- 
inal cavity, seriously injuring the mesentery or the intestinal loops. The 
uterus may be irrigated with unclean or strongly germicidal solutions, 
which may gain access to the peritoneal cavity. The amount of traumatism 
that may be inflicted by the unskilled operator is appalling. The body of 
the uterus has been completely separated from the cervix, both uterine 
arteries divided, and the uterus left attached only by the tops of the broad 
ligaments. In one case the bladder was torn and several feet of intestine 
had been pulled through the cervix. 

The symptoms of mutilation of the uterus of this type are those of 
shock and sepsis. Hemorrhage is usually profuse, and if the patient does 
react from the loss of blood, it is only to be stricken with the toxaemia of a 
peritonitis. The history of the injury may be difficult to elicit. 

The treatment must be prompt and thorough. It is only in the early 
cases that a successful result can be achieved. If possible, the patient 
should be removed at once to a well-appointed hospital. The first indica- 
tion is to combat the shock attending the injury and then to repair or 
remove the injured organ and provide suitable drainage. 

If there is no reason to suppose that the intestine or the mesentery has 
been torn, and if the uterus is severely injured, it should be removed through 
a vaginal incision ; otherwise an abdominal incision should be made, the 
intestinal tract carefully examined, and the injury repaired. In some cases 
extensive resection of the intestine has been required. Possibly no less 
favorable cases than many of these are encountered, and in spite of judi- 
cious and expert surgical treatment the patient may die of shock or sepsis. 



288 GYNECOLOGY 

Haematometra, Physometra, Pyometra. — When the cervical canal is 
imperforate congenitally or becomes obstructed, the secretions of the endo- 
metrium or the discharge from an intra-uterine disease cannot escape, so 
that the uterine cavity becomes gradually dilated to accommodate the pent- 
up secretion, menstrual or other, which slowly increases in amount until 
the condition known as hcematometra results (Fig. 37). In congenital stenosis 
of the cervical canal this is one of the phenomena incident to that particular 
form of gynatresia. 

Haematometra of non-congenital origin may be due to the accidental clo- 
sure of the cervical canal by operations upon the cervix, or to the pressure 
of new growths that obstruct the cervix. The most common cause of an 
acquired haematometra is a carcinoma of the endometrium, affecting espe- 
cially the region of the internal os. This condition is seen most frequently 
in old women, in whom previously there have probably been more or less 
atrophy of the cervix and contraction of the cervical canal. The infiltrated 
wall of the uterus becomes eroded, and the uterine cavity is increased in 
size by the breaking down of the carcinomatous areas and by the bleeding 
that takes place from the growth, until a tumor of considerable size may be 
formed. This is composed of the thinned-out uterine wall as a capsule, and 
its contents, carcinomatous debris and blood. If this carcinomatous tissue 
and blood become infected, pus formation ensues, so that the haemato- 
metra is converted into a pyometra. When degeneration progresses further 
and putrefaction occurs, gas is formed and is retained within the uterus, 
producing what is known as a physometra. 

These conditions may be suspected in the presence of uterine enlargements 
in old women that are more or less fluctuant, and in which there is little or no 
discharge from the uterus. In cases of haematometra due to congenital stenosis 
the history is usually sufficient ground on which to base a tentative diag- 
nosis. The most prominent symptoms are amenorrhoea, severe abdominal 
pain recurring at monthly intervals, and the gradual appearance of a pelvic 
tumor. In acquired cases cessation of the menstrual flow, periodic distress 
in the lower abdomen, and the appearance of a uterine enlargement 
are suggestive. 

A symmetric enlargement of the uterus, which is fluctuant, in association 
with the symptoms mentioned, affords reliable evidence on which to base 
the diagnosis. A positive diagnosis can be made only by noting the obstruc- 
tion to the passage of a sound into the uterus and the nature of the 
uterine contents. 

The treatment of haematometra, physometra, and pyometra, due to car- 
cinoma or other malignant diseases of the uterus, consists first in providing 
free drainage. W T hen fever is present, and in all cases of pyometra and 
physometra, it is advisable to carry out this procedure as a preliminary 
operation, and subsequently, after the local infection has subsided and the 
patient is in better condition, to perform a radical hysterectomy, unless the 
disease is so far advanced as to make this impracticable. 

In a majority of cases of pyometra or physometra the carcinomatous 
lesion has advanced beyond the hope of radical cure. The only procedure 
left for the surgeon is to make the patient as comfortable as possible, to 



DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 289 

reduce septic symptoms by keeping the cervical canal patulous, and to 
prevent a reaccumulation of the fluid within. The remarkable results that 
have been achieved in late years by the use of radium (see Chapter XL) 
make this form of treatment a distinct and hopeful addition to the therapy 
of advanced carcinoma. When radium is used there should be no curettement 
of the uterus. When radium is not available then the necrotic masses may 
be scraped away and the cavity packed with formalin (10 per cent.) or 
acetone (c. p.) gauze. 

Curettement. — By curettement of the uterus is meant a scraping away of the 
mucous membrane lining the uterine cavity. This is accomplished by 
means of an instrument known as the curette. 

Before introducing the curette into the uterine cavity the size and position 
of the uterus should have been determined by making a bimanual examina- 
tion. This should be confirmed by the passage of the uterine sound. After 
dilating the cervix, the curette is gently introduced into the uterus and passed 
on until it meets with the resistance of the fundus. The cutting surface of 
the instrument is then turned toward the posterior surface, and gently drawn 
forward toward the internal os in the median line. This procedure is re- 
peated in various directions until the entire posterior surface has been gone 
over. The scraping is then continued upon the lateral borders of the endo- 
metrial cavity and then upon the anterior surface. Up to this point the 
ordinary Sims' curette should be employed (Fig. 290). After the anterior and 
posterior surfaces of the endometrial cavity have been scraped clean, so 
that the direct impingement of the edge of the curette on the uterine muscle 
can be felt and heard, another form of instrument, known as the Martin 
curette, is passed to the tubal angle on either side, and swept across to the 
opposite tubal angle, and the procedure repeated several times. The thor- 
oughness of the scraping is important from the curative standpoint — the re- 
moval of every vestige of a diseased endometrium — and equally so from the 
diagnostic end, since all the endometrium must be removed and examined 
(the entire thickness of the endometrium cannot be removed, since the 
deeper parts are surrounded by the inner layers of the myometrium) 
in order to enable the surgeon to detect an incipient new growth which may 
occupy a small part of the endometrium and thus escape observation. 

During curettement the operator will be able to detect inequalities of the 
endometrial cavity caused by fibroid tumors that encroach upon it, or even 
endometrial polyps that project from the surface of the mucosa. If, owing 
to inequalities detected by the curette or from the history and symptoms, the 
presence of polyps is suspected, it is well to use a small curettement forceps, open- 
ing and closing the instrument in the suspected area and removing par- 
ticles of tissue thus secured. From the tissue removed during curettement 
the operator will often be able to determine correctly the nature of the 
endometrial lesion. In well-marked malignant disease, such as carcinoma 
or sarcoma, and in tuberculosis the particles removed will present a whitish, 
friable, cheese-like appearance, and the amount of curettings will be large. 
The endometrium may be markedly thickened, even in benign conditions, 
but the mucosa will come away in strips of considerable length, and when 
floated in salt solution the tissue will be pink and translucent. 
19 



290 



GYNECOLOGY 



Placental tissue comes away in fair-sized pieces ; the tissue is infiltrated 
with blood-clot, and upon close inspection villi may be detected. In hydati- 
diform mole the small cyst-like bodies of the degenerated chorion may be 
identified (Fig. 29S). Furthermore, the operator will usually be able 
to determine that this tissue lies in apposition with, but projects from, 
the uterine wall, whereas in malignant growths the tissue brought away is 



Ai 



y\ 



i^'M^ 




v 








Fig. 298. — Hydatidiform mole. (University Hospital.) 

dug out from the uterine wall itself. These guides are trustworthy only to a 
limited extent and after some experience with them. In doubtful cases the 
diagnosis should be withheld until after microscopic examination. In those 
cases in which a clinical diagnosis is made and is taken as the basis for 
further immediate treatment, the clinical opinion should subsequently be 
verified by histologic examination. (See also Diagnostic Curettement and 
Test Excision, page 121.) 



DISEASES OF THE ENDOMETRIUM AND MYOMETRIUM 291 

In order to prepare the curettings for microscopic sections, the entire 
quantity removed should be washed free of blood in salt solution and then 
placed in Zenker's fluid, in a 4 per cent, solution of formalin, or in 60 per 
cent, alcohol. 

The remainder of the technic belongs in the field of the pathologist, but 
it is incumbent upon him to embed the entire amount of tissue and take sec- 
tions from every part. Only in this way can error be prevented. If the 
uterus has been thoroughly scraped, it is unnecessary to use irrigation, and 
if bleeding does not occur, the introduction of a gauze pack is unnecessary. 
When the uterine cavity is enlarged, when hemorrhage is free, and particu- 
larly when placental or decidual tissue has been removed, a gauze pack for 
twenty-four hours is of considerable advantage. 

BIBLIOGRAPHY 

Axspach, B. M. : " Metrorrhagia Myopathica." Am. Jour. Obst, 1906, Hii, 1 ; Ibid. : " The 
Frequency and the Significance of Endometritis from the Standpoint of Treatment." 
Jour. Am. Med. Asso., 1908, 1, 842; Ibid. : "Hemorrhagic Uteri; Myopathic Uterine 
Hemorrhage." Surg., Gynec. and Ohst., 1908, ix, 315. 

Barrows, C. C. : " Intramural Abscess of the Uterus." Am. Jour. Obst., 191 1, lxiii, 575. 

Brothers, A. : " Accidental Perforation of the Uterus." Am. Gynec, 1903, ii, 323. 

Findley, O. : " Arteriosclerosis of the Uterus as a Casual Factor in Uterine Hemorrhage." 
Am. Jour. Obst., 1901, xliii. 

Gardner, W., and Goodall, J. R. : " Chronic Metritis and Arteriosclerotic Uteri." Brit. 
Med. Jour., 1906, iii, 1176. 

Gellhorn, G., and Ehrenfest, H. : " Syphilis of the Internal Genital Organs in the 
Female." Gyn. Trans., 1916, xli. 129. 

Goodall, J. R. : " The Involution of the Puerperal Uterus, with Special Reference to the 
Involution of Its Circulatory System." Am. Jour. Obst., 1909, lx, 921 ; Ibid. : " Climac- 
teric Hemorrhage." Am. Jour. Obst., 1910, lxi, 32. 

Kahlden, von, C. : " Ueber die sogenannte Apoplexia Uteri." Beitrage z. path. Anat., 1898, 
xxiii, 161. 

Kaji : " Zur Ovariellen yEtiologie uteriner Blutungen." Monatschr. f . Geburtsch. u. Gynak., 
1910, xxxii, 427. 

McIlroy, A. L. : " The Significance of the Wassermann Reaction in Gynecological Diag- 
nosis, with Special Reference to Uterine Hemorrhage." Brit. Med. Jour., 1912, ii, 1002. 

Pankow, O. : " Die Metropathia Hemorrhagica." Ztschr. f . Geburtsch. u. Gynak., 1909, 
lxv, 336. 

Reinicke, E. A. : " Die Sklerose der Uterinarterien und die klimakterischen Blutungen." 
Arch. f. Gynak., 1897, liii, 340. 

Shaw, J. : Chronic Metritis ; Its Pathology and Its Relation to Chronic Endometritis. 
Sherratt and Hughes, London and Manchester, 1906. 

Theilhaber, A. : " Zur Lehre von der Enstehung der Uterusblutungen." Miinchen med. 
Wchnschr., 1902, lxii, 1249 ; Ibid. : " Die sogenannte chronische Metritis, ihre Ursachen 
und ihre Symptome." Arch. f. Gynak., 1903, vii, 411. 

Whitehouse, H. B. : "Hunterian Lecture on the Physiology and Pathology of Uterine 
Hemorrhage." Lancet, London, 1914, i, 877. 

Williams, P. F., and Kolmer, J. A. : " The Wassermann Reaction in Gynecology." Am. 
Jour. Obst., 1916, lxxiv, 638. 



CHAPTER XVII 
MYOMATA OF THE UTERUS 

ETIOLOGY AND PATHOLOGY 

The etiology of myomata is obscure. That these tumors are at times 
congenital may be assumed from their presence between the horns 
of bicornate or double uteri. It is easily conceivable that fibroid rests 
in the urogenital strand might prevent the union of the Miillerian ducts. 
This evidence, however, is not convincing, since in a series of 1912 myomata 
operated on at the Konigsburg Clinic, there were but two cases associated 
with maldevelopment of the uterus, and of twenty-four cases of poorly de- 
veloped reproductive organs, myomata were observed in only two. 

The etiology of myoma appearing after birth has been the subject of 
considerable speculation. The clinical fact that these tumors are frequently 
associated with sterility or nulliparity has given rise to the suggestion that 
the periodic recurrence of menstruation, without the physiologic rest ob- 
tained during pregnancy and lactation, may exert a causative influence. It 
is more reasonable to suppose, however, that the 1 myomata themselves are 
the cause, rather than the result, of the sterility. In 1149 cases observed by 
Kelly and Cullen, more than 50 per cent were in women who had never been 
pregnant ; 307 of the patients were single, and over 32 per cent, of the mar- 
riages had been sterile. Myomata are most common in middle life, being 
rarely observed before puberty or after the menopause. In a series of 100 
consecutive cases, Hunner noted that 80 per cent, occurred between the thirtieth 
and the fortieth years. Laudau reports 42 cases occurring between twenty 
and thirty years — two were twenty years old. 

Myomata seem to affect the colored more often than the white race. In 
Hunner's series there were 31 colored to 69 white women. In the general run 
of cases the ratio of the two races is as one is to five. In the autopsy 
records of the Johns Hopkins Hospital 33.7 per cent, of all negresses over 
twenty had uterine myomata, whereas 10 per cent, of all white women over 
twenty were afflicted with these growths. 

Theilhaber believes that occasionally myomata are syphilitic in origin. 

It is not definitely known in what tissues of the uterine wall they origi- 
nate, but the blood-vessel walls are a suspected point, since the smallest 
seedling fibroids usually have a capillary in the center. Some authorities 
believe that myomata have their origin in the unstriped muscle-fibers of 
the myometrium. 

Histology. — Myomata are made up of unstriped muscle and fibrous 
tissue in varying amount. The fibrous tissue is ordinarily somewhat in 
excess of the proportion found in the wall of the uterus, and for this reason 
the tumors are often spoken of as fibro myomata. They are also commonly called 
fibroids. On gross section they present a glistening white surface, the 
fibrous tissue being arranged in concentric layers or whOrls ; the entire 
tumor may consist of one large whorl or of a number of smaller ones 
bound together by interlacing bundles of fibrous tissue (Fig. 304). The 
292 



MYOMATA OF THE UTERUS 



293 



tumor is usually sharply differentiated from the surrounding uterine muscle 
to which it is rather loosely attached by a zone of reticulated vascular tissue 
from which the nutrient blood-vessels are derived. 

Myomata, ordinarily, are not as well vascularized as the surrounding 
uterine muscle, the vessels which penetrate the tumor itself being small in 




Fig. 299. — Multiple subserous myomata. (Gynecological Laboratory, U. of P.) 

size and few in number. The surrounding uterine muscle may be very rich 
in blood-vessels, and sometimes the tumors themselves are well supplied, 
rarely even being angiomatous. The vessels in the capsule of the tumor 
are not infrequently enlarged, especially the veins, which present the ap- 
pearance of wide venous sinuses such as are commonly observed in sub- 



294 



GYNECOLOGY 



peritoneal tumors ( Fig. 299). The tumors, as a rule, are but slightly attached 
to their capsule, and can be shelled out rather easily. Myomata are usually 
multiple, and vary in size from that of a pinhead to enormous masses which 
fill the pelvic or abdominal cavity. In shape they are generally spherical, 
but irregular in contour, and so many combinations may occur that, as a 
result, the myomatous uterus may be of almost any conceivable shape. The 
consistency of the growth varies considerably, depending upon the propor- 
tion of fibrous and muscular tissue which it contains. The consistency and 
resiliency also may be affected by the various forms of degeneration which 
these tumors may undergo. 

Situation. — Myomata may occur in any part of the uterus, though they 

are more frequent in the fundus, and 
comparatively rare in the cervix. They 
very infrequently affect the vaginal 
cervix. Above the vagina the cervical 
tissue was the originating point of the 
tumor in 6.6 per cent, of the cases col- 
lected by Frankl. Smead found cervi- 
cal myomata in 5 per cent, of cases. 
They are usually multiple, from six to 
eight to as many as fifty tumors having 
been found in a single uterus. Fibroid 
tumors may be divided anatomically 
into three groups : First, interstitial ; 
secondly, subperitoneal, and thirdly, sub- 
mucous (Fig. 300). It is probable that 
the tumors all begin as interstitial 
growths, and that as they enlarge, they 
either remain at their point of origin, 
embedded in the muscle of the uterine 
wall, or migrate toward the serous sur- 
face and become subperitoneal, or to- 
ward the mucous surface and become 
submucous. 
Subperitoneal and submucous tumors may be extruded almost entirely, 
maintaining their connection to the uterus by a drawn-out portion of the 
uterine muscle, in this event becoming pedunculated (Fig. 301). The pedicle 
may undergo stretching and torsion, so that, finally, the tumor is released 
from its uterine attachment and is either extruded through the cervix in case 
it is a submucous growth, or detached from the uterus if it is a subperitoneal 
one. In the latter instance, the surface of the tumor has already become adher- 
ent to the omentum from which it receives a sufficient blood supply and 
upon which it is parasitic. When a myoma develops at the side of the 
uterine body and grows between the layers of the broad ligament, it is 
spoken of as intraligamentous (Fig. 302). If a tumor grows from the pos- 
terior surface of the cervix and enlarges beneath the peritoneum of Douglas' 
cul-de-sac, it is termed retroperitoneal. A tumor growing from the anterior 
wall, between the bladder and the vagina, is called subvesieal. 




Fig. 300. — Schematic longitudinal sagittal sec- 
tion of uterus showing various positions of myo- 
mata. (a) intramural; (b) subperitoneal; (c) 
submucous; (d) cervical. 



MYOMATA OF THE UTERUS 



295 



Growth. — The growth of myomata is usually slow. They may increase 
rapidly during pregnancy, or as the result of degeneration (cystic or sarco- 
matous) or suppuration. During involution following labor they diminish 
in size, and have been said in some instances to disappear. After the meno- 
pause, small tumors may stop growing, or even atrophy, but a great many 
of them show little tendency to do either, and in the latter event postpone 
indefinitely the cessation of menstrual life. On the contrary, there is great 
likelihood, at the time of the menopause, that myomata may undergo degen- 
eration or become complicated by malignant disease of the uterus. 

Uterine Changes. — The myomatous uterus is usually considerably hyper- 
trophied, and the endometrial cavity elongated and distorted. The hyper- 
trophy of the muscular wall of the uterus is greatest in the presence of 
interstitial tumors, and least where the growth is subperitoneal. 




Fig. 301. — Uterus opened, showing pedunculated submucous myoma. 

tory, U. of P.) 



(Gynecological labora- 



While the endometrium may be normal, it is very often affected by the 
pressure and circulatory disturbance produced by the tumor. Pressure 
causes overstretching, thinning and atrophy ; circulatory disturbance pro- 
duces oedema and hypertrophy. The apparent erosion and atrophy of the 
endometrium in submucous or interstitial centripetally developing myoma 
is in reality great attenuation and stretching of the endometrium. The 
stroma is very much thinned out and the few remaining glands lie parallel 
to the free surface of the tumor. In some cases the glands may entirely 
disappear. The blood-vessels of the endometrium may be dilated and ap- 
pear sinus-like. Usually they are displaced towards the periphery, where 
they present a concentric arrangement. Actual erosion is rare except where 
a submucous tumor is being extruded from the uterine cavity. There may 
be localized hypertrophies or polyps of the endometrium. Malignant affec- 
tions are not unusual, as will be considered later. 



296 



GYNECOLOGY 



Complications. — The complications which may be associated with myomata 
are many. The uterine appendages not infrequently are adherent, and may be the 
site of hydrosalpinx and of cystic degeneration of the ovaries. Sometimes the 
myoma is complicated by an acute and active infection of the tubes and ovaries 
(Fig. 303). The tubes are frequently involved. In a series of 1149 myomata re- 
ported by Kelly and Cullen, nearly one-half showed one or both tubes adherent. 
In this series hydrosalpinx (88) was the most frequent tubal lesion; chronic sal- 






A 



Fig. 302. — Intraligamentous fibroid. (University Hospital.) 



pingitis (48) and pyosalpinx (41) came next; tuberculosis (14), hematosal- 
pinx (12), tubo-ovarian abscess (14), cyst (2), and tubal pregnancy (6), were 
present. The ovaries showed pathologic changes as often as the tubes in 
this series, being adherent or showing some pathologic lesion in more than 
half the cases. Aside from adhesions, Graafian follicle cysts (68) and corpus 
luteum cysts (34) were the most frequent ovarian lesions — but dermoid 
cysts (17), papillomatous cystomata (12), multilocular adencmystoma (9), and 
adeno-carcinoma (8) were present. The ovaries were not infrequently hyper- 



MYOMATA OF THE UTERUS 



297 



trophied or cedematous, and actual fibromata (3) were found. Parovarian cyst 
was noted by Kelly and Cullen in 19 cases of this series. 

Degenerations. — The myomata themselves may undergo various forms 
of degeneration. In nearly every tumor in this series of Kelly and Cullen 
there were microscopic areas of hyaline degeneration. In many of these 
(114) the hyaline changes could be recognized macroscopically. When 
hyaline transformation is marked, liquefaction of the 7 degenerated areas may 




Fig. 303. — Myomatous uterus complicated by inflammatory lesions of the adnexa; pyosalpinx and ad- 
vanced peri-oophoritis. (Gynecological Laboratory, U. of P.) 

occur with the formation of smaller or larger collections of fluid (cystic 
degeneration) (Fig. 304). Circulatory obstruction may produce oedema; this 
usually occurs in association with hyaline degeneration. Calcareous infil- 
tration of a fibroid tumor is occasionally observed. This varies in degree 
from single to multiple " gritty " areas scattered throughout the myomatous 
tissue. Complete calcification is rare. Suppuration of myomata with the 
formation of abscess may occur, the infection reaching the previously de- 
generated (hyaline) tumor from the neighboring bowel in the case of sub- 



298 



GYNECOLOGY 




Fig. 304. — Interstitial myoma undergoing necrosis and cyst formation. (Stetson Hospital.) 




FlG. 305. — Necrosis or suomucous myoma. (Gynecological Laboratory, U. of P.) 



MYOMATA OF THE UTERUS 



299 



peritoneal tumors, and from the uterine cavity in the case of interstitial 
growths. Necrosis is the result of total, or nearly total, interference with 
the blood supply of a tumor. It is most common in pedunculated sub- 
mucous tumors (Figs. 305 and 306). A myoma may be so richly supplied with 
blood-vessels as to form an angioma. This is a rare occurrence. The 
lymphatic vessels upon the surface of a myomatous uterus, or even within 
the fibers of the tumor, are sometimes enormously dilated. Very rarely the 
myomatous tissue may be transformed into fat (lipomyoma). All benign 
forms of degeneration of myomata are more or less the result of an inter- 




Fig. 306. 



■Necrotic submucous myoma projecting from cervix through vulvar orifice. (University 
Hospital.) 



ference with the blood supply. They may also result from traumatism or 
torsion if the tumor is pedunculated. 

A myoma may become directly transformed into a sarcoma (myosar- 
coma). The frequency with which this is reported to occur depends upon 
the thoroughness with which all myomata are routinely examined. Winter 
found sarcomatous transformation in 4 per cent, of all cases. In the sub- 
mucous variety of myoma, 9 per cent, showed the sarcomatous changes. 
Frankl has found sarcomatous change in 2.3 per cent, of 514 personally 
studied myomata. 

A myoma cannot degenerate or be transformed into a carcinoma, but car- 



300 



GYNECOLOGY 



cinoma of the endometrium or cervix may complicate myoma. Myomata 
of the uterus seem to predispose to the development of carcinoma of the 
endometrium. This is indicated by the fact that in myomatous uteri corpus 
carcinoma is relatively much more frequent than cervical carcinoma; 
whereas the usual ratio of cervical to fundus carcinomata is as 15 is to 1, in 
the fibroid uterus the ratio is as 0.62 is to 1 (Winter). In a series of nearly 
5000 cases of myomata uteri (Kelly-Noble), carcinoma of the cervix was 




Fig. 307. — Cervical myor 



(Bryn Mawr Hospital.) 



present in 1% per cent.; carcinoma of the body of the uterus (Fig. 307) in 
1^ per cent. 

Pressure Effects. — The effect of myomata upon surrounding organs is 
due almost entirely to the mechanical displacement and distortion which 
these tumors produce. When a tumor is situated so that as it increases in 
size it is held within the pelvis, as is true of intraligamentous and cervical 
growths, it compresses the pelvic structures against the unyielding bony 
pelvis (Fig. 308). In this way pressure is brought to bear upon the bladder, 
urethra, ureters, and rectum. The bladder may be either pressed upon or 



MYOMATA OF THE UTERUS 



301 



displaced. In tumors originating from the anterior surface of the uterus 
below the vesical reflection of the peritoneum, it is not uncommon to have 
the bladder pushed upwards above the symphysis (Fig. 309). Tumors origi- 
nating in other areas, when large and tightly impacted, may displace the 
bladder almost entirely out of the pelvis, or may compress certain areas of 
the bladder, leading to partial obstruction of the urinary outflow and saccula- 
tion. There may also be adhesions between the superior movable surface of 





^'t-r . 7 


Recturr 




Myomata 




Uterus 




Bladder 


: ^ 




\ \ 




Fig. 308. 



-Multiple myomata of the posterior uterine wall, incarcerated in pelvis, causing pressure 
symptoms, and simulating pregnancy in a retroflexed uterus. 



the bladder and the anterior surface of the myomatous uterus. In rare 
instances the myoma may be so situated as to displace the bladder down- 
wards, exaggerating in one case coming under the writer's observation, a 
previously existing cystocele. As a result of interference with its normal 
function, the bladder wall may be hypertrophied, there may be distention 
and sacculation with retention of urine, and a low-grade cystitis. Vesical 
calculus has been noted in association with myomata. 

The ureters may be displaced or compressed. They are affected, as a 



302 



GYNECOLOGY 



rule, only by intraligamentous or subvesical tumors. Growths originating 
in those localities may elevate the ureters so that they course over the 
lateral surface of the fibroid, or they may be compressed between it and the 
bony pelvis. The ureter above the point of compression may become very 
much dilated (hydro-ureter). Thus the kidneys may become secondarily 
the seat of hydronephrosis. The changes in both ureters and kidneys at 
first are purely mechanical, and if the myoma is removed in time 
they disappear. 

There may be adhesions between the rectum and the fibroid uterus ; espe- 
cially is this likely to occur when other pelvic inflammatory lesions coexist. 
The sigmoid may be elevated by a tumor which grows posteriorly beneath 




FlG. 309. — Incarcerated subserous myoma causing intra-pelvic 
presssure: (B) bladder pushed up and pressed against pubic bone 
and anterior abdominal wall; (U) uterus with multiple interstitial 
myomata; (M) myomata; (M') subperitoneal myoma filling pelvic 
cavity, pushing up uterus; (R) rectum; (S) symphysis pubis. 



the peritoneum and between the layers of the meso-sigmoid. The com- 
pression of the rectum may be sufficient to cause partial obstruction, result- 
ing in chronic constipation, with atony and distention of the large bowel 
followed by autointoxication and anaemia from the absorption of toxins. 
Absolute obstruction from compression of the rectum probably never takes 
place, although it is marvellous that it does not occur in those cases in 
which the tumor completely fills and is tightly wedged in the pelvis. 

Pressure on the nerve trunks passing through the pelvis may produce 
pain at nearby or remote points. Compression of the veins may cause 
venous dilatation and cedema of the lower extremities. Pressure on the large 
arteries at the pelvic brim may cause a bruit. 

Circulatory Lesions. — It has long been noted that myoma patients fre- 



MYOMATA OF THE UTERUS 303 

quently (nearly 50 per cent, of the cases in Boldt's series) suffer from cardiac 
palpitation and dyspnoea, and exhibit murmurs and an increase or irregularity 
in pulse-rate. After operation thrombosis and embolism are more frequent 
in this than in any other class of cases. For these reasons myomata have 
been supposed to exert some peculiar specific effect upon the heart which 
produces a degeneration of the cardiac muscle. The mechanical resistance 
of the fibroid to the pumping of blood through its capsule, or the pressure 
exerted by the tumor upon the pelvic or abdominal vessels, has been alleged 
to be the cause of cardiac dilatation and insufficiency. Syphilis has been 
stated to be a cause of both myoma and heart disease. The cardiac condi- 
tion has been considered primary and the myoma secondary. A pathologic 
state of the ovary whereby it manufactures a noxious toxin has also been 
assigned as an explanation. When the facts are analyzed, we find that 
twenty-six cases of myoma uteri have been autopsied and recorded in which 
brown atrophy, fatty degeneration, and myofibrosis were found. Winter, 
analyzing these cases, concluded that there were but five in which no other 
cause but the myoma could explain the lesion. In 266 cases of myoma uteri 
of his own, which were carefully examined by an internist and then fol- 
lowed after operation, the heart was normal in 60 per cent. ; in 30 per cent, 
there were murmurs or impure tones ; in 6 per cent, there was dilatation and 
hypertrophy without valvular or myocardial disease ; in 1 per cent, there 
were valvular lesions, and in 1 per cent, myocardial lesions. All of these cases 
were reexamined after operation by the same internist as before, and fol- 
lowed up sufficiently to determine positively the condition of the heart after 
the benefit of the operation had made itself apparent. All of the valvular and 
myocardial lesions remained the same, while a large majority of the hyper- 
trophies and dilatations disappeared. Almost all of the murmurs or impure 
tones cleared up. As a result of this careful investigation Winter concludes 
that myomata influence the heart only by reason of the anaemia which they 
so commonly produce. The experience of Kelly and Cullen is in accord with 
this finding of Winter's, and in their series but two cases of myocarditis 
were noted. 

It can not be denied that in myoma advanced degeneration, as 
well as infection and necrosis, may produce toxins which cause changes 
in the cardiac muscle. Myoma patients in or beyond middle life 
commonly exhibit arteriosclerosis. The latter is not to be looked upon as a 
result of the myoma, but rather as an associated lesion. According to Theil- 
haber, the production of the myoma is the result of the arteriosclerotic ten- 
dency. The veins of the pelvis and lower extremities in myoma cases are 
not infrequently enormously enlarged and dilated as the result of pressure 
and interference with the return of the venous blood to the heart. This dila- 
tation of the veins, plus the impaired force of the circulation, plus the anaemia 
favors thrombosis and embolism. 

Anaemia is a common finding in patients suffering from myoma. This, 
as a rule, results directly from the profuse menstrual or intermenstrual 
flow. In more than half of the cases, according to Hunner, two-thirds 
according to Winter, at the time the patient comes under observation there 
is menorrhagia or metrorrhagia. In the worst cases with a very low haemo- 



304 GYNECOLOGY 

globin percentage, the bleeding usually has been a very pronounced and 
recent feature ; so that there is a very apparent connection between impover- 
ishment of the blood and the amount lost. In a certain number of cases, 
however, the degree of anaemia seems excessive in comparison to the amount 
of blood lost. In such cases the production of specific toxins by the tumor 
has been suspected. Degenerative changes, necrosis, infection, and suppu- 
ration of the tumor itself often explain the condition, and careful inquiry 
will usually elicit the fact that bleeding in the past has been profuse or that 
there are other causes for the blood abnormality, such as constipation with 
absorption and toxaemia, kidney disease, or some other concomitant lesion. 

SYMPTOMS 

Menorrhagia and Metrorrhagia. — The most frequent symptom of 
myomata of the uterus is profuse menstruation (menorrhagia). In cer- 
tain cases, as will be noted later, there may be intermenstrual bleeding. 
When the myoma is interstitial, the menorrhagia is the result of an increase 
in the amount of blood pumped into the endometrium (menstrual conges- 
tion) and the interference with the return flow through the veins due to the 
pressure of the tumor. As the growth increases the menstrual hemorrhages 
increase. If the location of the tumor changes, i.e., if it migrates towards the 
peritoneal surface, the interference with the endometrial circulation is less 
and the menstrual flow may notably diminish or become normal. If, on the 
other hand, migration occurs toward the endometrial cavity, the menstrual 
hemorrhage increases, because the interference with the endometrial circula- 
tion is greater. Besides the increase in the amount of the menstrual flow, 
the periods are usually prolonged and occur more frequently than they 
would normally. Thus a woman who has been in the habit of menstruating 
every month finds her periods recurring every three or every two weeks. 

The menstrual blood is the result of a diapedesis through the walls of the 
endometrial capillaries, so that the hemorrhage, up to a certain point, may 
be simply an increased diapedesis due to venous obstruction. If, however, 
the tumor becomes submucous, there may be in extreme cases an actual 
erosion of the endometrium covering the growth ; more commonly the capil- 
laries in the thinned-out mucosa rupture, under the influence of the men- 
strual congestion, so that, in addition to the hemorrhage at the time of 
menstruation, there are intermenstrual hemorrhages (metrorrhagia). 

When intermenstrual bleeding supervenes upon increased frequency of 
the menses and menorrhagia the loss of blood may be nearly constant. 
Except in the worst cases the menses may be recognized by an increase in 
the amount of the hemorrhage at periodic intervals. 

In the individual patient afflicted with myomata more than one or all of 
the anatomic varieties of tumor may be combined, so that the mechanics of 
the hemorrhage which have been given here are not always typically illus- 
trated. Submucous growths or myomata which distort the endometrial 
cavity are almost invariably present when the menstrual hemorrhage is 
marked. A single submucous myoma, the size of a pea, may occasion more 
alarming hemorrhage than tumors of an interstitial or a subperitoneal type 
of a much greater size. 



MYOMATA OF THE UTERUS 305 

Leucorrhoea. — Leucorrhoea may be noted during the menstrual interval. 
This may be mucus when the endometrium is hypertrophied, pus if there is 
infection of the cervix or endometrium, watery and foul-smelling if there 
is beginning necrosis of a submucous tumor, or putrid and purulent in the 
presence of a necrotic and infected submucous growth. The discharge, 
whatever its usual character, may be streaked with blood before and after 
the menstrual period. 

Pain. — Pain of some sort is present in over half of the cases observed by 
the clinician. It may be independent of the menstrual periods or limited to 
such times. The pain which is independent of the menses is usually due to 
the pressure of the myomatous uterus upon the surrounding parts. 

Subperitoneal myomata of moderate size, springing from the fundus of 
the uterus, rising free into the abdominal cavity, and uncomplicated by ad- 
hesions, give rise to no pain. After tumors attain a certain size and distend 
the abdomen, a feeling of fullness and distress, difficulty in breathing, etc., 
may be experienced. Intestinal or omental adhesions or neighboring in- 
flammatory processes (appendix, adnexa, etc.) may give rise to pain in 
connection with tumors of this type. 

Myomata springing from the body of the uterus or the cervix produce the 
greatest pressure pain; this is true especially of those tumors which grow 
between the layers of the broad ligament (intraligamentous) or distort and 
displace the bladder or the ureters. A myomatous uterus impacted in the 
pelvis may cause severe bladder or rectal symptoms or referred pain to 
nearby or distant parts (Figs. 308 and 309). Submucous tumors may give 
rise to painful uterine contractions. Acute agonizing pain may be occa- 
sioned by the torsion of a pedunculated fibroid tumor. Adherent, inflamed, 
or suppurating myomata may occasion pain. As is to be expected, myomata 
accompanied by adnexal lesions (salpingitis, oophoritis, pyosalpinx, ovarian 
abscess, etc.) are associated with more pain than uncomplicated cases. 

Frequent and painful urination is not an uncommon symptom and has 
been noted in nearly 25 per cent, of some series of consecutive cases of myo- 
mata. It varies in degree, depending upon the situation of the tumor and 
the associated changes that have been produced in the urinary system. 
There may be no discomfort except a frequent desire to empty the bladder 
as a result of the infringement of the tumor and a lessening of the bladder 
capacity, or the growth may be so placed that a complete emptying of the 
bladder is impossible, and there is constantly a certain amount of residual 
urine with ammoniacal decomposition, or there may be actual partial ob- 
struction to the outflow of urine, with consequent sacculation of the bladder 
and decomposition of the retained urine. In one case the urinary symptoms 
were typical of vesical stone, there being sudden stoppage of the stream, 
intense pain, and hematuria. 

Pressure upon the ureters may lead to obstruction of the ureteral output 
with renal crises. This in one patient was the first symptom which led to 
the discovery of a large fibroid tumor. Painful defecation is not uncommon 
when the tumor presses upon the rectum or there are hemorrhoids, and is 
very often accompanied by constipation and a feeling as if there were a 
foreign body in the rectum. 
20 



306 GYNECOLOGY 

Pain due to pressure on the pelvic nerves may be referred to the back, 
hips, or legs; numbness or loss of sensation in one or both legs is present 
in rare instances. The pain produced by myomata is usually increased just 
before and at the beginning of the menstrual periods, when the congestion of 
the pelvic organs is greater ; after the flow is well established there may be 
a subsidence of the pain to about its usual degree of severity, or even less, if 
the congestion has been much relieved by the hemorrhage. In the presence 
of submucous or interstitial growths there may be cramp-like pains through- 
out the flow. 

Circulatory Symptoms. — Myoma patients frequently (50 per cent.) ex- 
hibit an increase in the pulse-rate, palpitation, and dyspnoea. In such cases 
there are usually murmurs, systolic in time, heard best at the apex and 
transmitted to the axilla or pulmonary and aortic areas. There are many 
variations in these murmurs. They are, as a rule, the result of anaemia, 
deficient blood supply to the coronary arteries, and subsequent cardiac dila- 
tation. In rare instances brown atrophy or fatty degeneration has been 
present ; myocarditis or endocarditis may coexist with myoma without there 
being any relation between them. The heart murmurs and the cardiac 
symptoms so frequently observed in myoma cases usually disappear rapidly 
after removal of the myoma and cessation of the hemorrhage. The clinical 
evidences of anaemia and cardiac insufficiency are pallor, palpitation, dys- 
pnoea, chronic cough, and oedema of the lower extremities. The latter may also 
result from pressure of the tumor upon the pelvic veins, or it may be due to 
weakness of the heart or to renal insufficiency — sometimes to all of them 
combined. When the oedema is due to pressure alone it may be either uni- 
lateral or bilateral. (Edema produced by anaemia or by kidney insufficiency 
is bilateral. 

Anaemia. — The production of anaemia in fibroid tumor has already been 
explained (page 303). It is usually proportionate to the amount of hemorrhage, 
and the very marked degrees are almost never seen except in those patients who 
at the time of observation have considerable menorrhagia or metrorrhagia. 
Occasionally the anaemia, although not excessive, seems out of proportion 
to the bleeding. We must assume in such cases that at some time in the 
past the hemorrhage has been more profuse and that an anaemia produced 
at that time has persisted — the associated conditions preventing, or render- 
ing slow and difficult, a return of the blood to a normal state. In still other 
cases the anaemia may be associated with toxaemia from chronic constipation, 
kidney insufficiency, necrotic or infected tumors, etc. In the worst cases 
the haemoglobin may fall as low as 10 per cent., though it very rarely reaches 
this low point. Thirty to 40 per cent., however, is not uncommon. As a rule, 
the haemoglobin reading is between 60 and 70 per cent. The erythrocytes are 
usually diminished in proportion to the decrease in haemoglobin. 

DIAGNOSIS 

The ease with which a diagnosis can be made depends upon the number, 
size, and location of the tumors. Subperitoneal growths give the most char- 
acteristic physical signs. Interstitial and submucous tumors may present 
more difficulties. Large tumors are usually diagnosed more readily than 



MYOMATA OF THE UTERUS 307 

small ones ; a multiplicity of nodules in the uterus is a valuable diagnostic 
point (see also Chapter VIII). 

Abdominal Examination. — When the myomatous uterus is large enough 
to form an abdominal tumor the appearance of the enlargement is often more 
or less characteristic. As a rule, the enlargement is asymmetrical ; the tumor 
is more prominent on one side of the median line than on the other, and the 
abdominal wall curves abruptly from the summit of the tumor in both 
directions, viz., toward the symphysis and toward the epigastrium. The abdo- 
men portrays the actual condition, i.e., a hard, resisting body within the 
abdominal cavity, pushing the abdominal wall forward. By palpation the 
observations made on inspection are confirmed and the consistency of the 
tumor is noted (Figs. 133 and 134). A myoma usually gives a distinct sense of 
hardness and denseness, which readily distinguishes it from a pregnant uterus or 
an ovarian cyst. The surface of the growth may be knobby, and there may be 
smaller tumors on the surface of larger ones. If it can be determined by 
palpation that these smaller tumors are pedunculated, the diagnosis is all but 
positive. Percussion of a myoma distending the abdomen gives dulness 
over the prominence of the tumor and resonance surrounding it, except to- 
ward the pelvic brim. There are no auscultatory indications of a myoma. 
A bruit is heard in exceptional cases when the tumor overlies and presses 
upon some of the large veins at the pelvic brim. If the fibroid is intramural 
and distends the uterus symmetrically, it may be impossible to distinguish 
it from early pregnancy. In such cases it is advisable to keep the patient 
under observation until foetal movements and foetal heart sounds will be mani- 
fest if the woman is pregnant. It should be remembered, also, that preg- 
nancy and myoma may coexist. 

Bimanual Palpation. — Submucous tumors: The uterus is enlarged and 
more or less symmetrical. It is harder than the pregnant uterus. If the 
tumor is pedunculated, it sometimes dilates the cervix and presents itself in 
the cervical canal, or it may be extruded from the canal and hang by its 
pedicle in the vagina. In the case of small submucous tumors, a positive 
diagnosis can be made only after dilatation of the cervix and intra-uterine 
exploration by means of the linger, sound, or curette. Interstitial tumors: 
The cervix fuses directly with the enlarged fundus. It sometimes projects 
from the surface of the latter like a nipple from the breast. The uterus is 
usually somewhat irregular and of increased density. The uterine body can- 
not be outlined distinctly from the mass. This form of tumor is most diffi- 
cult to distinguish from pregnancy. Subperitoneal tumors: The uterus is 
studded with hard, knob-like protuberances. If they are pedunculated, the 
diagnosis is clear. When the growths are confined to one side of the uterus 
or to the fundus, the uterus can be outlined as a distinct but attached body. 
When the tumor is single and pedunculated, an ovarian growth must be 
excluded ; an attempt should be made to isolate the ovary upon the affecte-d 
side. If a subperitoneal myoma which rises out of the pelvis and distends 
the abdomen is pushed upward by the external hand, the uterus will imme- 
diately follow. If the tumor is held in that position and the uterus is drawn 
downward, the pedicle of the tumor may be felt at its attachment to the 
uterus by rectal palpation. 



308 



GYNECOLOGY 



Myoma of the uterus must be distinguished from solid and cystic 
tumors of the ovary. Normal pregnancy, ectopic pregnancy, pelvic inflam- 
matory masses, and carcinoma of the uterus or of the ovary may also simu- 
late myoma. The distinguishing features between myoma of the uterus 
and ovarian cyst are as follows : The abdominal distention and projection 
in a myoma are more abrupt and irregular than in the case of an ovarian cyst. 
The abdominal enlargement in myoma is apt to be asymmetrical, whereas 
with an ovarian cyst of sufficient size to cause abdominal distention, the 
enlargement is more apt to be equal to the right and left of the median line. 
The surface of the tumor is often more uneven in mvoma than in ovarian 




Fig. 310. — Myoma uteri and pregnancy (University Hospital). 

cyst, and on palpation of a denser consistency. On percussion ovarian cysts 
give fluctuation, while myomata do not. The percussion wave in an ovarian 
cyst may be indistinct when the tumor is multilocular, and all the loculi are 
small and filled with gelatinous substance. Sometimes a myoma has under- 
gone cystic degeneration, and then it may show a wave of fluctuation, al- 
though this is a very exceptional occurrence. In myoma there is dulness 
over the greacer prominence of the growth and resonance surrounding it, 
but the area of dulness is neither as symmetrical nor as absolute as in the 
ovarian cyst which is apt to hug the anterior abdominal wall more closely 
than an irregular myoma. 

On bimanual palpation in a case of myoma it can be determined that the 
abdominal mass is in direct connection with the uterus. It is sometimes 



MYOMATA OF THE UTERUS 309 

possible to distinguish between a myoma of the uterus and an ovarian cyst 
by picking up the ovaries on either side by bimanual palpation. Although it 
is not always possible to do this, in every doubtful case an effort should be 
made to find the ovaries, and especially the ovary on the suspected side. In 
some cases of ovarian cyst it is possible to outline the uterus lying either in 
front of or behind the cystic mass. In other cases the abdomen as well as 
the pelvis may be so distended that bimanual examination is unsatisfactory. 
In such cases occasionally a distinct wave of fluctuation may be felt through 
the vaginal wall upon tapping the abdominal surface. 

The chief difficulty in differentiating myomata from ovarian cysts will be 
found in those of moderate size. An ovarian cyst which is not adherent 
can be pushed away from the uterus without causing as direct a tug upon 
that organ as would be occasioned by pushing up a myoma. Likewise, in 
ovarian cyst an impulse transmitted to the growth above the pelvic brim is 
not felt so distinctly at the cervix. When the ovarian cyst is intraliga- 
mentous in type, or adherent, the distinguishing features between it and a 
fibroid tumor are the consistency of the enlargement, the presence of fluctua- 
tion, and the associated physical findings, such as the presence of other fibroid 
nodules in the uterus and the size of the uterus itself. 

The differential diagnosis between myoma and pregnancy is frequently 
very difficult, especially if the tumor is of the intramural or interstitial type 
(Fig. 310). The enlargement of a pregnant uterus in a great majority of 
instances is more symmetrical than that of a myomatous one. but there are 
some myoma cases in which it requires considerable study to make a diag- 
nosis. In order to differentiate between the two conditions the history and 
the associated signs of pregnancy must be relied upon. The softening of the 
lower uterine segment (Hegar's sign), fcetal movements, fcetal heart sounds, 
and ballottement should be looked for. In case of doubt, the solution of the 
question is found after observing the case for a couple of months. At the 
end of this period, with no appearance of the signs characteristic of preg- 
nancy, the diagnosis, as a rule, will be unmistakable. There have been in- 
stances where an abdominal pregnancy which had undergone lithopedion 
formation has been mistaken for a myoma, and the shape of some large sub- 
peritoneal tumors has at times suggested the outlines of a foetus in utero. 
The differential diagnosis may be facilitated by a rontgenogram. After the 
sixth month the Rontgen ray is useful in the differential diagnosis of pregnancy 
as the shadow of the fcetal skeleton may then be recognized in a well-executed 
negative. There is apparently no tendency to abortion or miscarriage from 
the use of this means of diagnosis. The Abderhalden serum reaction may 
be tried, but is not likely to be of value. In some cases anaesthesia may be 
required before a satisfactory diagnosis, can be made. 

The diagnosis between myoma and pelvic inflammatory masses, as a rule, 
is not difficult, but occasionally some doubt may arise. An abscess sur- 
rounded by a considerable amount of exudate and induration may exactly 
simulate a myoma. Usually, however, the induration, the sense of deep 
fluctuation, and the associated history and signs of inflammatory pelvic 
trouble serve to distinguish between them. 



310 GYNECOLOGY 



TREATMENT 



From what has been said, it can be seen that myomata, although not 
essentially malignant, are capable of much mischief, and after a certain 
time may become very dangerous to their host. A small tumor of an inter- 
stitial or a subperitoneal type, developing late in life, showing no ten- 
dency to grow with any degree of rapidity, giving rise to no symptoms, 
and possibly discovered by accident during pelvic examination, may be 
regarded with equanimity and let alone. Such a patient should always 
be carefully watched, and from time to time examined, so that an 
increase in the rapidity of growth or any complications may be detected 
at once. 

If any rule were to be made in the treatment of myomata producing 
symptoms it should be to remove them by a surgical operation within a 
short time after they had been detected. This would be justified by the 
fact that most of the myomata producing symptoms ultimately require 
operative treatment, and many times when operation is delayed the case 
becomes complicated and dangerous or even fatal degenerations and compli- 
cations ensue, or the operation is rendered more difficult by an increase in 
the size of the tumor. 

Palliative treatment, therefore, is only considered because sometimes, on 
account of the condition of the woman as a result of the hemorrhage and 
other effects of the tumor or because of advanced age and general ill-health, 
it may be inadvisable to operate at all, or, at any rate, to proceed with an 
operation until the strength and resistance of the patient have been in- 
creased by suitable preparatory treatment. The control of hemorrhage is 
the most immediate and pressing indication in a majority of the cases in 
which anaemia is marked and the circulatory condition of the patient is bad. 
Absolute rest in bed during the menses, or whenever hemorrhage is apt to 
occur, and the use of remedies which arrest hemorrhage by contracting the 
uterus or by increasing the coagulability of the blood will often be effectual. 
Ergot, pituitary extract, stypticin, and horse-serum may be tried for this 
purpose. If more heroic measures are necessary a gauze tamponade of the 
cervix may be tried with full aseptic precautions. Curettement is not advis- 
able for the purpose of controlling hemorrhage because it may hasten the 
necrosis of a submucous tumor by interfering with the blood supply, and by 
favoring entrance of pathogenic organisms. The Rontgen ray and radium 
are valuable therapeutic agents ; either will check the bleeding in a ma- 
jority of cases so that the patient may be put in good shape for a subse- 
quent radical operation. At the present time the weight of evidence is 
against the use of the Rontgen ray or radium as curative agents in cases 
of myoma uteri, except under certain conditions (see Radium and Rontgen 
Ray Therapy, Chapter XL). 

With the measures to prevent further hemorrhage must be combined 
those which promote the restoration of the blood and circulatory system to 
a normal condition. Iron and arsenic, blood transfusion, cardiac and renal 
stimulants, all may be required. 

The indication for operation is all the more urgent when the myoma is 



MYOMATA OF THE UTERUS 311 

growing rapidly, when the woman is approaching the menopause, or a 
recent irregularity in the hemorrhage suggests the probability of a compli- 
cating malignant growth of the endometrium. 

Choice of Operation. — The operative treatment of myoma uteri varies 
from the simplest to the most formidable undertaking. Myomectomy is the 
removal of the tumor from the uterus, the latter being left in situ. Hysteromyo- 
mectomy is the removal of the uterus with the tumor. Either of these opera- 
tions may be undertaken through an abdominal incision. The operation 
selected in a case of myoma depends upon the number and location of the 
tumors, and the desirability in the individual case of preserving the men- 
strual and the reproductive functions. A single tumor attached to the 
vaginal part of the cervix may be subjected to vaginal myomectomy. Kelly 
and Cullen report eighty-four cases of vaginal myomectomy with five deaths ; 
with one exception the patients who died were septic or in a desperate 
state when admitted, owing to infection, necrosis, or gangrene of the tumor. 

A submucous tumor which has become pedunculated and projects 
through the cervical canal can be removed by torsion or by ligation and 
division of the pedicle. A submucous tumor lying within the cervix or the 
lower uterine segment may be enucleated (vaginal myomectomy) after 
bisecting the anterior uterine wall to secure adequate exposure. Multiple 
submucous tumors or single ones not easily accessible demand hystero- 
myomectomy. Hysteromyomectomy for cervical myomata by the vaginal 
route is feasible when the myomatous uterus is small, but the abdominal 
route possesses so many advantages that it is generally recognized as the 
procedure of choice. In the operative treatment of myomata affecting the 
body of the uterus the abdominal operation is the only one which need be 
taken into consideration. The choice between myomectomy and hystero- 
myomectomy depends upon the factors already mentioned. The more 
numerous the tumors, the more is hysteromyomectomy indicated, and the 
greater the distortion of the uterine body the less likely is myomectomy to 
be satisfactory. Degeneration of the myoma and suppurative or malignant 
complications are absolute contraindications to myomectomy. The cases 
most suited to myomectomy are those in which the number of tumors is 
small ; single tumors or at most not more than four or five ; the tumors are 
favorably situated, especially subperitoneal or interstitial, so that they can 
be removed without serious technical difficulties and without encroaching 
upon the uterine cavity ; the cases give no evidence of degenerative changes ; 
there are no malignant complications ; there is no associated suppurative dis- 
ease of the adnexa, and there is not so much distortion of the uterus by the 
tumor that after myomectomy it would be a misshapen and useless organ. 

The age of the patient and her desire to bear children is another impor- 
tant factor in reaching a decision. While there is no reason to be conserva- 
tive in a patient nearing the menopause who would be unlikely to conceive 
or in one who had no desire to bear children, the probability of gratifying 
the maternal instinct should be preserved whenever possible in younger 
women. In this class conservative myomectomy may yield the most 
happy results. 

Objections to myomectomy are : That occasionally it is a more serious 



312 GYNECOLOGY 

and a more dangerous operation than hysteromyomectomy ; that it must be 
done with the most refined aseptic technic in order to avoid infection and 
dangerous post-operative adhesions ; that it may be necessary subsequently 
to operate again to remove the uterus on account of the development of other 
myomata which escape detection at the time of the first operation, and that 
pregnancy, after myomectomy, may end in abortion, or that labor may be 
complicated by a rupture of the uterus. 

With the progressive refinement in operative technic, and a careful limi- 
tation to suitable cases, myomectomy has become a safe operative procedure 
(Mayo, \Ym. J., 157 consecutive cases with one death; Kelly and Cullen 
report a mortality of 5.4 per cent, in 296 abdominal myomectomies), the 
primary mortality being less than that of hysteromyomectomy when the 
cases are properly selected. Hysteromyomectomy is the operation of 
necessity in bad cases : myomectomy is the operation of choice in good 
operative risks with favorably situated tumors. 

If care is exercised and all of the nodules removed, the subsequent de- 
velopment of unrecognized myomata is uncommon (Mayo — two in 157 
cases). Although no more than the " greater number " of the myomectomy 
patients (Mayo's series) were traced afterwards, 18 in their series of 296 
cases required subsequent operation (hysterectomy in 12). 

JVhen the uterus is removed with the myomata, what shall be done with 
the adnexaf The advantage in preserving the ovaries lies in the avoidance 
thereby of the disagreeable and annoying symptoms of an artificial meno- 
pause. The disadvantage is that the adnexal organs left behind may subse- 
quently become diseased and require a second operation for their removal. 
Both possibilities have been exaggerated, the one by those who champion 
the conservative plan, and the other by those who favor the radical plan. 
An artificial menopause is not often distressing within a few years of the 
menopause, and if the adnexa are entirely normal the chances are that they 
will remain so if in the performance of hysteromyomectomy their blood 
supply is carefully preserved. In a patient approaching or past the meno- 
pause age it is better, as a rule, to remove the adnexa. while in younger 
women it is preferable to allow them to remain. In women under thirty-five 
every eftort should be made to preserve the ovaries. If one ovary is dis- 
eased and the other is healthy, the diseased one should be removed and the 
other left in situ. It is better to do this than merely to resect the diseased 
area and to allow the rest of the ovary to remain. If possible the rule of 
either letting an ovary alone or taking it out entirely should be adopted. 
The resection of a part of an ovary is often followed by a recurrence of 
trouble, so that it should be avoided if possible, especially if the opposite 
ovary is entirely healthy. Resection of both ovaries may be required when 
they are diseased, even though the woman is young, or the worst one may 
be removed in toto and the other one resected. If it is not possible technically 
tQ leave either ovary in situ, a portion of one of them may be transplanted into 
the fat of the abdominal wall. When the ovaries are conserved the tubes 
also should be allowed to remain if they are healthy. This assures a pres- 
ervation of the ovarian blood supply. If the tubes are diseased, however, 
and require removal, they should be neatly trimmed off the top of the 



MYOMATA OF THE UTERUS 313 

broad ligament and the catgut sutures used to control the bleeding tied as 
closely as possible to the tube. 

When a myoma has undergone malignant degeneration, or is compli- 
cated by a carcinoma of the body of the uterus or of the cervix, removal of 
the entire uterus including the cervix, panhysterectomy, is absolutely neces- 
sary. On account of the danger of overlooking carcinoma of the cervix in a 
myomatous uterus and because a cervix left behind after supravaginal hys- 
terectomy has subsequently become carcinomatous, some operators recom- 
mend complete hysterectomy, as a rule, instead of supravaginal amputation. 
There are many objections to such a course. Complete hysterectomy is a 
more difficult and a more dangerous operation than supravaginal hysterectomy. 
It is objectionable in married women because it shortens the vagina. Fur- 
thermore, such a course is unnecessary. An early carcinoma of the cervix or 
the body of the uterus complicating myoma may be detected previous to, or 
at the time of, operation if the cervix is carefully examined and the endo- 
metrial cavity curetted. By this precaution the danger of overlooking malig- 
nant trouble is avoided. In doubtful cases the major operation should be 
postponed until curetted particles or excised pieces of tissue can be sub- 
mitted to microscopic examination. If curettement of the uterus has been 
unsatisfactory or impossible on account of distortion or inaccessibility of the 
endometrial cavity, the uterus should be opened in the operating room immedi- 
ately after the supravaginal amputation. If, then, there are any evidences 
of malignant complications the cervix should be removed forthwith. 

In spite of the precautions above detailed, occasionally an incipient cancer 
of the cervix will be overlooked or a cancer will develop in the cervix sub- 
sequent to a supravaginal hysteromyomectomy. Therefore, any patient who 
has bloody discharge following hysteromyomectomy should be examined 
without delay in order to detect trouble of this nature. 

Carcinoma of the cervical stump in an early stage should be dealt with 
by excision ; if the disease has not advanced beyond the cervix an abdom- 
inal operation, with dissection of the ureters and wide excision of the para- 
metrium and vaginal vault, is the procedure of choice. In late cases, vaginal 
excision with the cautery may be tried. If radium is available it is pref- 
erable to any form of operation. 

OPERATIVE TECHNIC 

All operations for myomata of the uterus are preceded by dilatation 
of the cervix and curettement. The purpose of this plan is three- 
fold. First, it insures thorough disinfection of the vagina so that if pan- 
hysterectomy becomes advisable the vaginal part of the operative field is 
already prepared. Furthermore, if there is any reason to believe that the 
cervix or uterine cavity is not sterile an attempt can be made to make it so, 
as described on page 324. Secondly, hypertrophied mucosa is removed by 
curettement for the reason that if the operation of removal of the tumor is 
limited to a conservative myomectomy, the uterus is left in a healthier 
state than if an hypertrophied endometrium were allowed to remain. Thirdly, 
a curettement prevents a failure to recognize already existing malignant dis- 
ease in the cervix or body of the uterus. If the character of the curetted 



314 



GYNECOLOGY 



particles is such as to leave no reasonable doubt of their malignant nature, 
a panhysterectomy is indicated. If the contrary is true and they are un- 
questionably benign, myomectomy or supravaginal hysteromyomectomy 
may be selected. If there is any doubt as to the existence of malignancy, 
further operative procedure should be postponed until careful microscopic 
study of the tissues can be made. 

Abdominal Myomectomy. — After a median incision and exposure of the 
uterus, the exact position and relations of the tumor or tumors is carefully 
investigated. If the ca^e is a suitable one for myomectomy, the uterus is 
surrounded by a double layer of gauze packs so as to completely isolate it 
from the neighboring areas. Pedunculated subperitoneal tumors may be 
removed by a simple wedge-shaped incision of the pedicle, the two lips of 
the wound being brought together with sutures. If the tumor is large, 
and the pedicle is small and vascular, the peritoneal reflection from the 




Fig. 311. — Abdominal myomectomy. Line of incision through capsule of myoma. 

uterus may be circumcised and pushed back toward the uterus and the 
pedicle ligated with fine catgut, the peritoneum then being drawn over the 
cut surface of the pedicle and united with a fine running suture. If the 
tumor is sessile or intramural, one of two methods may be used for its ex- 
traction. By the first, after the incision has divided the surrounding tissue 
down to the capsule of the growth, an attempt is made by a blunt dissection 
to follow its circumference, separating the tumor from the uterine wall. 
This will be successful in small and well encapsulated growths. In larger 
ones, and those more firmly attached, a better plan is to carry the incision 
directly through the tumor to its opposite pole ; in other words, to bisect the 
growth, and then, catching each half with a vulsellum, separate each side in 
turn from its bed in the uterine wall. Bleeding may be controlled during 
this process by manual compression of the vessels of the broad ligament on 
either side, or intestinal forceps protected with rubber may be applied to the 
broad ligaments. As a rule, manual compression is to be preferred. After 



MYOMATA OF THE UTERUS 



315 



the tumor has been enucleated the more prominent bleeding points should 
be caught with forceps and ligated free or with mattress sutures. The bed 
of the tumor is then filled up by the introduction of fine interrupted or con- 
tinuous catgut sutures, while the peritoneal wound is approximated by a 
running suture of fine catgut. It is very important that the entire bed of the 
tumor be completely approximated or filled up, and that the peritoneal inci- 
sion be closed in such a fashion that there is no raw area exposed to 
which adhesions might occur (Figs. 311 to 315). 




Fig. 312. — Abdominal myomectomy. After making Fig. 313. — Abdominal myomectomy. After ex- 
the incision the myoma may be bisected and each posing the myoma it may be shelled out [by 
half caught in turn and dissected out. blunt dissection. 





Fig. 314. — Abdominal myomectomy. The bed of 
the myoma is carefully filled up with running cat- 
gut sutures. Large bleeding points are tied. 



Fig. 315. — Abdominal myomectomy. The uterine 
incision is closed with a suture of fine catgut; care- 
ful approximation of the peritoneal edge is secured. 



Where a number of nodules are to be removed from the same uterus, it 
is an advantage, if possible, to so plan the incisions that they lie in the same 
general direction, or in such a way that one peritoneal incision will answer 
for the enucleation of more than one tumor. The latter is rarely feasible. 
In some cases it may be desirable, in order to avoid a dead space or badly 
coaptated surfaces, to remove some of the uterine wall. There is no objec- 
tion to this when it becomes necessary, although it should be avoided when 
possible. Although the uterus may appear quite misshapen and out of pro- 



316 



GYNECOLOGY 



portion at the conclusion of the operation, subsequent involution may 
restore the organ to approximately normal form. 

Vaginal Myomectomy. — Vaginal myomectomy may be a very simple 
operation consisting of no more than a V-shaped division of the pedicle of a 
small tumor. Great difficulty, however, is encountered in tumors of consid- 
erable size, which spring from the cervix and greatly distend the vagina and 




Fig. 316. — Supravaginal hysteromyomectomy with bilateral salpingo-oophorectomy. The ovarian 
vessels and the round ligament have been tied. The utero-vesical fold of peritoneum is about to be divided. 



perineum in nulliparous women, if the pedicle is broad, and the attachment 
of the cervix difficult to reach and expose by means of the usual specula and 
retractors, a paravaginal incision should be made as a preliminary step in 
the operation. This affords easier access to the operative area. The tumor 
should then be divided in the median line directly up to its attachment with 
the cervix, and each half shelled out separately. The excess of capsule 
should be cut away, and the wound closed with interrupted catgut 



MYOMATA OF THE UTERUS 



317 



sutures. Vaginal myomectomy is sometimes employed for submucous 
growths which cannot be exposed until the uterine cavity has been opened 
by hysterotomy. In performing this operation, the anterior surface of the 
cervix and uterus are exposed by dividing the anterior vaginal wall trans- 
versely, close to its reflection, and then pushing up the bladder from the 
uterine surface. The incision of the uterine wall is made directly in the 
median line, and a succession of vulsella are placed on either side, from below 
upward, as the uterus is drawn down, until a point sufficiently high to 
expose the tumor has been reached. After removal of the growth the line 




Fig. 317. — Supravaginal hysteromyomectomy with bilateral salpingo-oophorectomy. A 

curved clamp has secured the uterine extremity of the broad ligament. The tube and ovary 

have been cut away from the broad ligament as far as the clamp. 



of incision in the anterior uterine wall is closed with interrupted catgut 
sutures. The vaginal wall is then united to the cervix. 

Hysteromyomectomy. — After the preliminary preparations have been 
completed, a median abdominal incision should be made, the uterus exposed, 
and the intestines packed off from the pelvic cavity. The position and num- 
ber of the tumors are noted, as well as the condition of the adnexa. If the 
adnexa are adherent and easily accessible, they should be released from 
adhesions at once, and the fibroid uterus pulled up through the incision. 
This is always possible in tumors of moderate size which are not intraliga- 
mentous or subvesical in position. If the tumor has developed from a point 



318 



GYNECOLOG^ 



low in the uterus, from the cervix, for example, and has grown between the 
layers of the broad ligament or the mesosigmoid, or if it lies beneath the 
bladder, early delivery will not be feasible, and certain modifications of 
the operation will have to be carried out. 

A simple hysteromyomectomy with bilateral salpingo-oophorectomy is 
performed as follows : The uterus is drawn over to one side of the pelvis and 
a point in the opposite broad ligament outside the ovary, which is free from 
blood-vessels, is selected. A catgut ligature is passed through this space and 







Fig. 3i8. — Supravaginal hysteromyomectomy with bilateral salpingo-oophorectomy. 

The round ligament and the broad ligament have been divided, exposing the cellular tissue 

as far down as the cervix, the bladder has been pushed away from the front of the cervix. 

The position of the uterine artery is being located with the finger. 



tied over the top of the broad ligament, securing the ovarian artery and 
veins (Fig. 316). A second ligature is now passed about the round liga- 
ment at a point somewhat nearer the uterus than the first ligature. This 
procedure is carried out upon the opposite side. A clamp is then placed 
along the lateral surface of the uterus, embracing the origin of the round 
ligament, the uterine extremity of the tube, the utero-ovarian ligament, and 
the utero-ovarian anastomosis, the end of the clamp pressing close to the 
side of the uterus so as to occlude the uterine vessels above the point where 
the division of the cervix is contemplated (Fig. 317). The broad ligament 



MYOMATA OF THE UTERUS 



319 



on one side is divided to the median aspect of the ligatures which have been 
applied, down to the end of the clamp which has been placed on that side 
of the uterus (Fig. 318). The vesical reflection of the peritoneum is then 
picked up from the anterior surface of the cervix and divided from the in- 
cision which has been made in the broad ligament across the front of the 
cervix to a corresponding point on the opposite side. The division of the 
broad ligament on the opposite side is then carried out in a similar manner. 
The uterine artery and veins on each side are located by palpation, and a 
suture passed about them with a needle (Fig. 319) ), the suture embracing a 
few of the lateral muscular fibers of the cervix. These sutures are tied, and 
the vessels are cut half an inch above it. The cervix is now divided trans- 
versely, by means of a wedge-shaped incision. The operation may be car- 




Fig. . 319. — Supravaginal hysteromyomectomy with bilateral 

salpingo-oophorectomy. A ligature has been thrown around the 

uterine vessels. Division of the cervix may now be done. The 

clamp controls the reflux circulation. 



ried out from left to right, or from right to left, if the operator so desires, 
tying the vessels on the side of approach and catching them with forceps on 
the opposite side after division of the cervix ; or all the vessels on both sides 
may be clamped and ligatures applied after the uterus has been removed 
(Figs. 320 and 321). After double ligation of both uterine vessels, the lips of 
the cervix are brought together in an anteroposterior direction, the outer 
approximating suture at either side of the cervix being made to include the 
end of the round ligament which is drawn over to it. The raw surfaces 
are covered by approximating the vesical reflexion of the peritoneum to the 
peritoneum of the posterior surface of the broad ligament and Douglas' 
pouch (Figs. 322 and 323). 

When adhesions of the uterus itself, or the adnexa, complicate the method 
of operation just described, they should be freed at once and the operation 
reduced to an uncomplicated series of maneuvers. If, however, the adhe- 



320 



GYNECOLOGY 



sions are dense, it may be advisable to begin the hysterectomy on the most 
accessible side, approaching the difficult side from below, after division of 
the cervix (Fig. 320). When both sides are seriously involved, but the fundus is 
accessible, the uterus may first be bisected in the median line as far as the cervix. 
Each half of the uterus is then in turn divided, the uterine vessels secured, 
and the separation of adhesions effected by working from below upward. 







Fig. 320. — Hysteromyomectomy from side to side. 

If the fundus is also buried in adhesions, the vesical peritoneum should 
be divided, the bladder pushed off the anterior surface of the uterus, and 
the cervix located and divided transversely from the median line to either 
side, until the uterine vessels are exposed. After ligating them the proxi- 
mal section of the cervix should be caught with a tenaculum and pulled 
upward, and the separation of the uterus and adnexa proceeded with from 
below upward. 



MYOMATA OF THE UTERUS 



321 



The operator may thus vary the technic of operation to suit the condi- 
tions which confront him in the individual case. An intraligamentous tumor 
on one side may be approached from the opposite side, enucleation of the 
tumor being attempted only after the opposite broad ligament has been 
secured and divided, and the cervix cut across. The uterine vessels on the 
affected side may then be carefully secured and the enucleation of the tumor 




Fig. 321. — Supravaginal hysteromyomectomy with bilateral salpingo-oophorectomy. Showing detail 

of ligating the clamped uterine artery; the vessel is first tied against the cervix and then picked up with 

an artery forceps and ligated individually with the same suture. 



effected from below. Sometimes it may be of advantage and feasible to 
ligate the ovarian pedicle and the round ligament on the difficult side before 
attacking the opposite broad ligament. The point of division of the cervix 
must be sufficiently low to expose the cellular tissue of the broad ligament 
close to the lower pole of the tumor or beneath it. 

In the case of a subvesical development of the tumor the first step in the 
operation should be an incision of the vesico-uterine fold of peritoneum and 
the separation of the bladder from the front of the uterus and the tumor. 
21 



322 



GYNECOLOGY 



After this has been accomplished the uterus will be more easily delivered, 
and the operation can be concluded often in the customary manner. 

All plans of operation remain more or less difficult and potentially danger- 
ous until the uterus and tumor are mobilized. Usually, it is desirable to have a 
firm grasp upon the myomatous uterus, and although this may be obtained 
in the case of small tumors by means of Museaux forceps, the corkscrew 
holder of Doyen is much to be preferred when the growth is large. Some 
mobility may be gained in almost every case by dividing the round ligament 
on one or both sides. 





FlG. 322. — Supravaginal hysteromyomectomy with bilateral salpingo- 

oophorectomy, showing the cupping of the cervix which has been done 

during the supravaginal amputation and the introduction of the figure of eight 

suture to close the cervical stump. 



The technic of hysteromyomectomy is varied, also, by the method of 
disposal decided upon for the tubes and ovaries. If the adnexa on one side 
are to be preserved, the division of the broad ligament on that side should be 
to the inner extremity of the tube, and through the utero-ovarian ligament. 
If the tube is diseased, and the ovary alone is to remain, the ligation of the 
mesosalpinx should be carried out in the same way as will be described under 
salpingectomy, the round ligament and the utero-ovarian ligament being 
ligated close to the uterus. If both adnexa are healthy, both ovaries and 
both tubes may be left. Conservation of the adnexa is unadvisable after the 



MYOMATA OF THE UTERUS 



323 



age of thirty-eight, not only because the conserved structures will soon be- 
come useless, but also because they may later become diseased. Whether 
the ovary of one or both sides is conserved in conjunction with the tube, 
care should be taken that it is not left in too much of a dependent position. 
To avoid such a disposal, suspension to the round ligament may be prac- 
tised (Figs. 324 to 326). 

After hysterectomy the cervix should be suspended by attaching to it the 
cut extremity of the round ligament on both sides. When the operator has 





Fig. 323. — Supravaginal hystero-myomectomy with bilateral salpingo-oophorectomy, showing the trans- 
fixion of the round ligament with a suture that draws it between the outer raw lips of the cervix and anchors 
it in that position ; showing also the suture of the peritoneum which covers in all the raw surfaces. 

this in view at the beginning of the operation, he may provide for it by 
dividing the ligaments close to the fundus of the uterus. It should never 
be practised if it places tension on the pedicle of the infundibulo-pelvic liga- 
ment. One side at least may almost without exception be handled in 
this way. 

In the performance of hysteromyomectomy, both the ovarian and the 
uterine vessels should be tied twice on each side. In addition to the two ligatures 
which secure each uterine artery, and are passed so as to include a 
little of the cervical tissue, the ends of the upper suture after the knot is 
tied should be passed about the uterine vessels themselves after the latter 



324 



GYNECOLOGY 



have been isolated and grasped by a forceps (Fig. 321). In cutting through 
the cervix a wedge-shaped incision should be made so as to secure easy 
approximation of the cervical flaps. 

If previous to operation the uterine cavity has not been invaded by 
any sort of intrauterine treatment, the cervical canal may be re- 
garded as sterile, and no particular precautions are necessary upon divid- 
ing it ; when, however, as a result of preliminary intrauterine treatment per- 
formed with a careless technic, or because of a necrotic submucous tumor in 
which the endometrium ma3^ be the site of infection, the cervical canal may 

be infected, the greatest care 
must be exercised at the time 
it is opened. In such cases, pre- 
vious to the abdominal section 
and after the preliminary dilata- 
tion and curettement, the entire 
uterine cavity, or as much of it 
as possible, should be packed 
with gauze saturated with the 
tincture of iodine. Under these 
circumstances the amputation of 
the uterus and the invasion of 
the cervical canal should be per- 
formed as the very last step in 
the abdominal removal of the 
uterus. The incision across the 
cervical canal should be made by 
means of a cautery knife, after 
very careful isolation of the area 
with gauze sponges. The ex- 
posed mucosa of the cervix 
should be destroyed with the 
cautery, or disinfected with car- 
bolic acid, and the instruments 
and sponges used in this particu- 
lar part of the operation should 
be discarded. 

Panhysterectomy. — Panhys- 
terectomy is the operation which 
may be preferred for myomatous uteri when the cervix is diseased, as by marked 
cystic degeneration, hypertrophy, or laceration with marked eversion ; pan- 
hysterectomy is demanded when a fibroid tumor is complicated by a cancer 
of the endometrium or the cervix; panhysterectomy is necessary when the 
tumor occupies such a low position, or is so intimately involved with the 
cervix that it cannot be removed to the exclusion of the cervix. Panhyster- 
ectomy for myomata may be easy or difficult, depending upon the size, 
number, and position of the nodules. In simple cases the technic resembles 
that of panhysterectomy for cancer of the endometrium (see page 345). 
Panhysterectomy for fibroid tumor complicated by cancer of the cervix 




Fig. 324. — Supravaginal hysteromyomectomy with con- 
servation of the adnexa. The position of the uterine clamp 
is the same as in Fig. 317, but the round ligament, the 
tube and the utero-ovarian ligament are ligated close to 
the clamp and the broad ligament is divided between. 



MYOMATA OF THE UTERUS 



325 





Fig. 325. — Supravaginal hysteromyomectomy with conservation of the adnexa. 
Anchoring the round ligaments to the cervix. 




! \ V V 



A W 




# 



3K* M 



Fig. 326. — Supravaginal hysteromyomectomy with conservation of the adnexa. The operation 
completed and the raw surfaces covered. 



326 



GYNECOLOGY 




FlG. 327. — Diffuse adenomyoma of uterus. From Cullen's Adeno 
myoma of the Uterus. (W. B. Saunders Co.) 



must be more radical, the same technic being employed as in panhysterec- 
tomy for cancer of the cervix (page 349). 

In difficult cases of pan- 
hysterectomy for fibroid 
tumor, especially when the 
tumor is intraligamentous, 
great care is necessary to 
protect the ureters from in- 
jury. The base of the broad 
|1 ligament may be so dis- 
torted that the uterine ves- 
sels are difficult to secure, 
and in ligating them the 
ureter may be inadvertently 
tied. The only way to pre- 
vent such a misfortune is 
to identify all structures as 
they are exposed. By far 
the best plan is to deliber- 
ately dissect the ureters, 
and then retract them out 
of harm's way. The ureter 
may be found displaced 
to the outer side of an 
intraligamentous tumor, 
or it may be lifted up by a 
tumor developing beneath, 
so that it courses over the 
superior aspect of the 
growth. 

ADENOMYOMA 1 
Pathology. — An adeno- 
myoma of the uterus, as 
the name implies, is a new 
growth consisting of myo- 
m a t o u s and glandular 
tissue. The adenomatous 
formation may be a diffuse 
one (Fig. 327), more 
or less uniformly 
involving the entire uterine wall, and sometimes completely encircling the 
uterine cavity, or it may be limited to an area at one cornu of the uterus 
(Fig. 328), or along the lateral surface of the uterus in an intraligamentous 

1 Adenomyositis uteri is the term applied by Frankl to cases of diffuse thickening of 
the uterine wall with infiltration of the myometrium by gland-like formations resembling 
those found in adenomyomata but without any circumscribed tumor. He believes the 
condition to be of inflammatory origin, although in some cases no trace of inflammation 
can be found ; these latter he calls "Adeno-Myosis Uteri." The glands may originate from 




Fig. 328. — Longitudinal transverse section of uterus, showing adeno 
myoma of tubal angle. (Gynecological Laboratory, U. of P.) 



MYOMATA OF THE UTERUS 327 

position, or it may be within the inner layers of the myometrium, forming a 
submucous tumor. Adenomyomata are not well circumscribed like the myo - 
mata ; they cannot be shelled out from the area which they occupy. Adeno- 
myomata also affect the isthmal extremity of the tube and the inguinal part 
of the round ligament. Cases have been described in which they were situ- 
ated beneath the lower pole of the kidney and alongside the cervix, closely 
related to the vaginal vault. Adenomyomata of the rectovaginal septum 2 
have been described by Cullen and others. 

The essential histological features of adenomyomata, in whatever posi- 
tion found, are interlacing bundles of fibrous and muscular tissue, enclosing 
within their strands patches of glands and stroma closely resembling the endo- 
metrium. In the diffuse adenomatous formation, this glandular tissue undoubt- 
edly is an ingrowth from the endometrium, and Cullen has shown that the same 
is true of a large proportion of cornual and intraligamentous adenomyoma. 

Symptoms. — Adenomyomata exhibit the general symptoms and course 
of the ordinary myomata. The first symptom usually is an increase in the 

post-foetal proliferation of the endometrium, or misplaced parts Of the Miillerian ducts — 
not from the Wolffian system. When the gland formations are found in the outer layers 
of the uterine wall, they may have originated in the serosa. 

It is possible that adenomyomata of the outer extremity of the round ligament, the 
lower pole of the kidney, and the mesosalpinx (epi-oophoron) may be derived from rests 
of the Wolffian body, as believed by von Recklinghausen. By reason of their structure, 
adenomyomata sometimes become cystic. Carcinomatous degeneration of the glands may 
also occur. 

2 Adenomyoma of the recto-vaginal septum at first forms a very small tumor in the 
vaginal vault just behind the cervix; or it may be recognized first as a round or irregular 
thickening, not over one cm. in diameter, behind and usually attached to the cervix. The 
growth usually spreads in a diffuse and irregular manner, involves the adjacent anterior 
rectal wall, and spreads into one or both broad ligaments, until finally everything in the 
pelvis may be firmly glued into one mass. The symptoms depend largely on the manner 
in which the growth extends. Small adenomyomata give little trouble. Rectal involvement 
may cause pain ; neuralgic pain may be caused by implication of the pelvic nerves : kidney 
pain by compression of the ureters. The menses are sometimes painful. If the mucosa 
of the adenoma opens into the vagina there may be vaginal hemorrhage at the menses ; if 
the mucosa of the tumor extends through the rectal mucous membrane, there may be some 
rectal bleeding at the menses." 

Cullen's conclusions as to treatment are as follows : " First, when small discrete nodules 
exist in the posterior vaginal vault they may be readily removed through a vaginal incision, 
as was so successfully done by Stevens. 

" Second, when the growth occupies the posterior surface of the cervix and extends 
laterally, the ureters should be dissected out carefully and a complete abdominal hysterec- 
tomy be performed. 

" Third, if the growth be firmly adherent to the rectum a wedge of the rectum should be 
removed, together with the uterus. It has been found best, after freeing the uterus on all 
sides, to open up the vagina anteriorly and laterally. The uterus and the rectum can be 
then lifted further out of the pelvis, thus facilitating the removal of the necessary wedge 
of the anterior rectal wall. The uterus can be used as a handle and the necessary rectal 
tissue and the uterus removed as one piece. 

" Fourth, when the lumen of the bowel is greatly narrowed a complete segment of the 
rectum should be removed, together with the uterus, and an anastomosis made. 

" Fifth, in desperate cases, where everything in the pelvis is glued together, an ideal 
procedure is out of the question. The patient in such a case cannot stand a long operation, 
and if she could a satisfactory result could not be obtained. Under such conditions it 
would be better to cut across the sigmoid, invert the lower end, close it, and bring the upper 
end out through the abdominal wall of the left iliac fossa, making a permanent colostomy. 
When the patient has to some extent regained her strength, the uterus, the lower portion 
of the rectum, and the broad ligament tissue can be shelled out as one piece. 

" These growths, while histologically not malignant, remind one of glue. Unless they 
are completely removed, further trouble is liable to occur." (Cullen.) 



328 GYNECOLOGY 

length of the menstrual periods. Pain at the menstrual period is particu- 
larly pronounced, and is evidently due to the increase in the tension within 
the 'tumor, the islands of mucosa being congested like the true endometrium, 
and hemorrhage occurring into the glands. Adenomyomata do not attain 
the enormous size of nbromyomata. Not infrequently they are associated 
with inflammation of the adnexa. 

Diagnosis. — The diagnosis of adenomyomata in distinction from nbro- 
myomata is rarely practicable. 

' Treatment. — The treatment is hysterectomy with preservation of the 
ovaries in younger women. 

BIBLIOGRAPHY 

Baer. B F. : " Supravaginal Hysterectomy Without Ligature of the Cervix in Operation 

for Uterine Fibroids. A New Method"." Trans. Am. Gyn. Soc., Phila., 1892, xvii, 235. 
Beyea, H. D. : " Conservation of Ovaries and Functionating Uterine Tissue in Hystero- 

Myomectomy." Amer. Jour. Obst, 1901, xliv. 
Clark, J. G. : " Fibroid Tumor of the Uterus." Progressive Medicine, 1906 ; Ibid. : " The 

Cause and Significance of Uterine Hemorrhage in Cases of Myoma Uteri.*' J. H. H. 

Bull., 1899, x. 94-96. 
Clark, J. G., and Xorris, C. C. : " Conservative Surgery of the Pelvic Organs in Cases of 

Pelvic Peritonitis and of Uterine Myomata." Surg., Gyn. and Obst., 1910, xi, 398. 
Cullex, T. S. : " Adenomyoma of the Recto- Vaginal Septum." Trans. Amer. Gyn. Soc. 

1917, xlii, 481 ; Ibid. : Adenomyoma of the Uterus. Saunders, Phila., 1908. 
Deaver, J. B. : " Operative Treatment of Fibromyomatous Uterine Tumors." Trans. Sect. 

O. G. and A. S., A. M. A., 1916, p. 319; Ibid.: "Hysterectomy for Fibroids of the 

L'terus." Amer. Jour. Obst., 1905, Hi, 858. 
Doran, A. : " The Disappearance or Absorption of Fibroid Tumors Before the Menopause." 

Jour. Obst. and Gynec. Brit. Empire, 1004, vi, 141 ; Ibid. : " The Disappearance or 

Absorption of Fibroid Tumors of the Uterus." Jour. Obst. and Gyn., Brit. Empire. 

1904, vi. 
Doyen : " Hysterectomies Abdomenales." Arch. Prov. de Chir., Dec, 1892 ; Ibid. : 

Technique Chirurgicale. Paris, 1897. 
Fexwick, H. : " On Cardiac Defeneration from Pressure of Abdominal Tumors." The 

Lancet, 1888. i. 
Fleck: " Myom u. Herzerkrank, in ihren Genetischen Beziehung." Arch. f. Gynak., 1904, 

lxx, Xo. 1. 
Gebhard : Pathology Anat. des Weiblichen Sexualorgane. Leipzig, 1899. 
Goffe, J. R. : " A New Method of Supravaginal Hysterectomy, etc." Amer. Jour. Obst.. 

1890, xxiii, 372. 
Huxxer, G. L. : " One Hundred Consecutive Cases of Myoma of the Uterus." American 

Medicine, July 11, 1903. 
Kelly, H. A. : " Hysteromyomectomy by Continuous Incision." J. H. H. Bull., 1896, vii, 27. 
Kelly, H. A., and Cullex, T. S. : Myomata of the Uterus. Saunders, Phila., 1909. 
Knox, J. H. Mason : " Compression of the Ureters by Myomata Uteri." Am. Jour. Obst., 

1900, xlii. 
Legueu, F. : " Des troubles Urinaires Provoques, par les Fibromes du col Uterin." Jour. 

d'Urologie, 1912, i. 33. 
McGlinn, J. A. : " The Heart in Fibroid Tumors." Trans. Amer. Gyn. Soc, 1913, 38, 482. 
Mayo, Wm. J. : " Some Obervations on the Operation of Abdominal Myomectomy for 

Myomata of the Uterus." Surg., Gyn. and Obst., 1911, xii. 97: Ibid.: " Myomas of the 

Uterus." Jour. Am. Med. Assc, 1917, lxviii. 887. 
Noble, C. P.: "Myomectomy." N. Y. Med. Jour., 1906, lxxxiii : Ibid. : "The History of 

the Early Operations for Fibroid Tumor." Amer. Jour. Obst., 1899, xl : Ibid. : " Fibroid 

Tumors ; Degenerations and Complications." Jour. Am. Med. Asso., December 8, 1906. 
Olshausex : " liber die Wahl der Operation bei Myomen." Cent. f. Gynak., 1902, Xo. 1. 
Pellaxda : La Mort par Fibromyomes Uterins. Paris, 1905. 
Pfahler, G. E. : Rontgenotheraphy in Uterine Fibroids and L'terme Hemorrhage." Amer. 

Jour. Obst., 1915, lxxii, 79. 
Pick, L. : " 1st das Vorhandensein der Adenomyome des Epioophoron Erwiesen ? " Cen- 

tralbl. f. Gynak., 1900, xxiv, 389-397. 



MYOMATA OF THE UTERUS 329 

Piquand: "Fibromes et Cancers Uterins.' r Annales de Gynecol, et d'Obstet, 1905. 
Prvor: "A New and Rapid Method of Dealing with Intraligamentous Fibromata." Med. 

News, 1894. 
Recklinghausen, von, F. D. : Die Adenomyome und Cystadenome der Uterus und 

Tubenwandung — In Anhang : Klinische Notizen zu den Volumonosen Adenomyome 

de Uterus. W. A. Freund, Hirschwald, Berlin, 1896. 
Sampson, J. A.: "The Blood Supply of Uterine Myomata." Trans Amer. Gyn Soc, 1911, 

xxxvi, 239; Ibid.: "The Influence of Myomata on the Blood Supply of the Uterus, 

with Special Reference to Abnormal Uterine Bleeding." Surg., Gyn. and Obst., 1913, 

xvi, 144 ; Ibid. : " The Influence of Myomata on the Blood Supply of the Uterus, etc." 

Trans. Amer. Gyn. Soc, 1912, xxvii, 156. 
Smead, L. F. : "Cervical Fibroids." Am. Jour. Obst., 191 1, lxiv, 790. 
Stimson : " Ligation of the Uterine Arteries in Their Continuity, in Hysterectomy." N. Y. 

Med. Jour., xlix, 1889. 
Sutton, J. B. : " Fibroids of the Uterus." Science Reviews, Ltd., London, 1913. 
Theilhaber, A. : " Der Zusammenhang von Myomen mit Internen Erkrankungen." 

Monatsch. f. Geb. u. Gynak., 1910, Bd. xxxii, H. S., 455. 
Veit, J. : " Ueber Vaginale Myomectomie." Zeit. f . G. u. G., 1896, xxxiv. 
Vineberg, H. N. : "What Is the Fate of the Ovaries Left in Situ After Hysterectomy? 

Surg., Gyn. and Obst., 1915, xxi, 559. 
Webster, J. C. : "A Consideration of Fibroid Tumors of the Uterus Based Upon a Study 

of a Series di Two Hundred and Ten Cases Treated Surgically." Am. Med., 1905, 401. 
Winter : " Die Wissenschaftlichen Grundlagen der Conservative Myomoperation." Zeit. 

f . Geb. u. Gynak., 1905, lv ; Ibid. : " Die Wissenschaftlichen Begrundung der Indika- 

tionen zur Myomoperation." Zeit. f . Geb. u. Gynak., 1905, lv ; Ibid. : " Die Malignen u. 

Benigen Degeneration der Uterusmyome." Zeitsch. f. Geb. u. Gynak., 1906, lvii, 8. 
Zweifel: Ueber die Behandlung der Myoma. Cent. f. Gyn., Bd., 1899, xxiii. 



CHAPTER XVIII 
MALIGNANT TUMORS OF THE UTERUS 

CARCINOMA OF THE UTERUS 

Situation. — Carcinoma may affect either the cervix or the body of the 
uterus. A cervical carcinoma may have its origin in the mucosa of the 
vaginal portion of the cervix or in that of the cervical canal. Carcinoma in 
the body of the uterus grows from the endometrium. 

Etiology. — The cause of carcinoma is not known. In the majority of cases 
it occurs at about the time of the menopause ; it is rare before the age of 
thirty-five, but sometimes develops after the age of fifty. The disease is 
believed to be less frequent in the negro than in the white race. The poorly 
nourished and those who live amid unhygienic surroundings are said to be 
predisposed. That the disease is infectious has been repeatedly insisted 
upon, and many instances of the apparent prevalence of cancer in certain 
localities, and of the development of the disease in different persons living 
in the same house (" cancer house "), at various times, have been observed. 
Direct transference of cancer from a patient to the attending physician or a 
nurse has not been observed, and the experimental proof of the infectious 
nature of the disease has yet to be adduced. Among other causes to which 
the occurrence of carcinoma has been attributed are the abnormal prolif- 
eration of embryologic inclusions of alien tissue. There seems to be little 
evidence that heredity plays an important part. What is known as the 
biologic theory, namely, that cancer is the result of repeated traumatisms 
which finally induce an unlimited proliferation of the irritated epithelial 
cells, seems to apply particularly to carcinoma of the cervix, for except in 
women who have borne children, the disease is very rare in this situation. 
The apparent exceptions to this rule, on careful inquiry, will often be found 
to have been the subjects of some operative procedure upon the cervix, such 
as dilatation. Although this clinical fact may admit of other interpreta- 
tions, it is, nevertheless, true that childbirth with its attendant laceration of 
the cervix predisposes to the development of carcinoma in the cervical por- 
tion of the uterus. Statistics collected by Frankl show that only 3 per cent, 
of cervical carcinomas develop in nulliparous women. This does not seem 
to apply to carcinoma of the body of the uterus, which affects nulliparae 
quite as often as women who have borne children, and in them some other 
explanation for the occurrence of carcinoma must be found. Sometimes, 
unquestionably, the irritation produced by a fibroid nodule in the wall of the 
uterus favors the development of carcinoma of the endometrium, and in 
these cases it may be that a diffuse or a circumscribed hypertrophy of the 
endometrium has preceded the development of the carcinoma. Carcinoma 
of the cervix occurs about ten times as frequently as carcinoma of the body 
of the uterus. 
330 



MALIGNANT TUMORS OF THE UTERUS 



331 



CARCINOMA OF THE CERVIX 

Pathology. — Carcinoma of the cervix may partake of one of two histo- 
logic types: (i) The squamous-celled carcinoma (epithelioma) when it 
springs from the squamous epithelium covering the vaginal surface of the 
cervix (Figs. 329, 330 and 331) ; (2) the columnar-celled or glandular variety, 
adenocarcinoma, when it springs from the high columnar epithelial cells of 
the folds and glands of the cervical mucosa (Fig. 336). As carcinoma de- 
velops most frequently in a cervix which has been lacerated and everted, it 
is often difficult, by gross examination, to determine in which of the situa- 



iW" 


f 








Fig. 329. — Epithelioma of the cervix (Cullen's Cancer of the Uterus, 
W. B. Saunders Co.). 



tions noted it has originated. EA'en by histologic examination it may be 
impossible in the later stages to determine whether the growth was origi- 
nally an epithelioma or an adenocarcinoma, since in advanced cases they 
both present very much the same features. Epithelial pearls may, how- 
ever, serve to distinguish an epithelioma and a glandular structure 
an adenocarcinoma. 

Carcinoma of the vaginal surface of the cervix has a tendency to spread 
to the neighboring mucous membrane of the vaginal vault, and then to in- 
volve the cervical canal. Carcinoma of the cervical canal is more likely to 
penetrate the wall of the cervix and invade the cellular tissue between the 
layers of the broad ligament. Both varieties, however, may extend in either 



332 



GYNECOLOGY 




Fig. 330. — Early epithelioma of the cervix. (Anspach in 
Martin's Surgical Diagnosis, Lea and Febiger.) 



of the directions mentioned, 
and as the disease progresses 
usually do. Carcinomata 
spread by a continuity of 
growth upon the surface and 
by the deportation of cancer 
cells along the lymph radicals 
of the broad and uterosacral 
ligaments (Figs. 332 to 334). 
These lymph-vessels pass from 
the cervix and the vaginal 
vault through the paravaginal 
and paracervical cellular 
tissue to the hypogastric and 
the iliac glands and to those 
lying alongside the rectum 
over the sacrum. In advanced 
of a more malignant type, the 



cases, and even in some of the early ones 
obturator glands may also be involved. 

In advanced carcinoma of the cervix, the involvement of both the sur- 
rounding and distant structures may be very extensive. The vesicovaginal 
septum may be extensively infiltrated, so that ultimately the tissue between 
the bladder and vagina breaks down with the formation of a vesicovaginal 
fistula. Infiltration of 
the rectovaginal sep- 
tum may also occur, 
but, as a rule, much 
later, and it is not so 
likely to result in a 
fistulous communica- 
tion between the bowel 
and the vagina. The 
bases of the broad liga- 
ments and of the utero- 
sacral ligaments may 
be converted into in- 
d u r a t e d, unyielding 
areas of stony hard- 
n e s s , which fix the 
structures within their 
grasp. The ureters 
may be completely sur- 
rounded, and there may 
be some obstruction to 
the passage of urine 
through them, causing 
hydroureter and hydro- 
nephrosis, even though 




Fig. 331.— Squamous cell carcinoma of the vaginal cervix. The entire vagi- 
nal surface ot the cervix is mvolvpH fr,vn P rn1ntri^i T ~v,™-o<-,-v~r tt ~t r> \ 



(Gynecological Laboratory, U. of P.) 



MALIGNANT TUMORS OF THE UTERUS 



333 






O m 



1*8 i 

->P 

— -J ~ 



3 5 5L 

p " a> 
3 P o 

5? ^ 3 
~ D-i« 

gS.3 



2 3 < 

— O Cl 

<5 3 F 



fD O 



^ 5-0 

"< 0> 2. 

S 3" 

3°^ 



P 0> 

-t p 

3^ 





< O 




334 



GYNECOLOGY 



there is no actual carcinomatous infiltration of the ureter itself. 

Carcinomatous infiltration of the pelvic nerves occurs in late cases. The 
infiltration and lymphatic enlargement may exert sufficient pressure upon 
the veins to produce oedema of the lower extremities. When the lymphatic 
involvement has progressed to a certain extent, the lumbar glands become 
diseased, and then there may be metastasis to distant parts of the body. 
Remote metastasis is not so frequent, except in the last stages, in carcinoma 
of the cervix as in carcinoma of the body of the uterus. Though carcinoma 
of the cervix spreads in all directions, it does not affect the fundus of the 
uterus except in the most advanced cases. 

Coincident with the progressive extension and advancement of the car- 




FiG. 333- — Diagrammatic sketch to show the spread of epithelioma 

of the cervix, sagittal and transverse sections; black area represents 

original site; dots, the early areas of extension; crossed lines, the 

ultimate involvement. 



cinomatous disease into new areas, there is a breaking down, a necrosis, and 
an infection of the areas previously or originally involved. Thus, in an ad- 
vanced case, the cervix is often entirely destroyed, and in its place an 
excavated ulcer, with hard, indurated edges bleeding easily on touch, is 
found which may be covered with a necrotic, foul-smelling discharge. The 
ulceration is the result of an insufficient blood supply to the new growth 
plus an infection (Fig. 335). The streptococcus is a frequent dweller in 
carcinomatous ulcers. Carcinomatous stenosis, or occlusion of the cervical 
canal, with coincident infection, may lead to the production of pyometra. 

From what has been said it is evident that cancer of the cervix may 
appear in three clinical forms : 

First, the proliferating or vegetating (cauliflower) form — usually an epi- 



MALIGNANT TUMORS OF THE UTERUS 



335 



thelioma beginning on the vaginal part of the cervix and forming a luxuri- 
ant mass which projects into the vaginal vault. 

Second, the infiltrating or indurated — usually an adenocarcinoma begin- 
ning in the cervical canal and infiltrating its way into the broad ligament, 
causing stony induration and hardness. 

Third, the ulcerating or the excavating form — either the proliferating or 
infiltrating type — after the carcinomatous tissue has broken down and been 
discharged, with the formation of large ulcers or craters. 

Symptoms. — There are no symptoms pathognomonic of cancer. The 
most frequent symptom of cervical cancer is hemorrhage (Fig. 336). Rarely 




Fig. 334. — Diagrammatic sketch to show the spread of adeno-car- 

cinoma of the cervix: sagittal and transverse sections; black area 

represents original site; dots, the early areas of extension; crossed 

lines, the ultimate involvement. 



at the start this may take the form of an increased menstrual flow ; usually, 
in the early, and always in the later stage, it occurs between the menstrual 
periods, either without any apparent reason, or induced by douching, sexual 
intercourse, defecation, riding over a rough road, or by something that acts 
as a trauma to the delicate carcinomatous villus, which consists of a capil- 
lary blood-vessel surrounded by a thin layer of carcinoma cells. The amount 
of hemorrhage may be very slight, and usually in the early case consists of 
but a few drops ; in exceptional cases, however, it may be profuse. Preced- 
ing the onset of hemorrhage there may be a discharge having the appear- 
ance of a leucorrhoea or an increase in one which existed previously, or again 
the discharge may become streaked with blood, or assume a reddish or a 
brownish appearance. These are the only subjective symptoms of an early 



336 



GYNECOLOGY 



carcinoma ; they are often regarded with equanimity by the patient, and 
considered a natural phenomena incident to the menopause. 

Later on, when the disease has become advanced and hemorrhage is 
more frequent and profuse, there is a discharge of putrid, broken-down car- 
cinomatous tissue ; the woman complains of pain from carcinomatous infil- 
tration of the broad ligaments, bladder, bowel, ureters, or pelvic nerves ; 
functional disorders of the neighboring viscera occur, and a cachexia de- 
velops, w T hich is partly the result of hemorrhage and partly due to disturb- 
ance of the excretory functions and the absorption of toxins from the necrotic 
cancer tissue. It. should never be forgotten that the latter symptoms are 
those of a hopeless case of carcinoma! The recognition of malignant disease 







Fig. 33S-— Advanced epithelioma of the cervix. The vaginal cervix has been destroyed by the growth 
which has reached the internal os. Typical cauliflower type of growth. (Gynecological Laboratory, U. of P.) 

after such symptoms have appeared is usually of no avail. As soon, there- 
fore, as a patient complains of the slightest irregular hemorrhage, a thor- 
ough examination should be made, for it is only in this way that carcinoma 
may be recognized in an early stage. 

Diagnosis. — The physical characteristics of an early carcinoma of the 
cervix depend upon the variety of the growth and its point of origin. As 
the most common form is the squamous-celled variety arising from the 
vaginal surface of the cervix, it is usually plainly evident to inspection after 
exposing the cervical lips. Its appearance is suggestive of the ordinary cer- 
vical erosion or eversion of the cervical lips, but it has certain points of 
variation from a benign eversion or erosion which may be brought out by a 
closer examination. 



MALIGNANT TUMORS OF THE UTERUS 



337 
















jnox.&roctel , /«. 



Fig. 336. — Histological section of finger-like projection from cervix, showing cause of hemorrhage; (a) 
indicates a delicate capillary, which is surrounded by from two to three layers of squamous epithelium, 
and appears in a cross section of a typical finger-like outgrowth. At (b) is a finger of tissue containing 
two blood-vessels, or possibly two sections of the same vessel, if it has been a very tortuous one. (c) is a 
large blood-vessel. Note the very fragile walls, consisting of a layer of endothelium (d) and external 
to this a few young connective tissue cells. Covering the surface of this vessel are a varying number of 
layers of squamous cells; at (e) three or four layers, the one next the vessel being cuboidal; at (/) only 
one layer, (g) indicates solid areas, rich in epithelial cells. In some places blood-vessels are scattered 
sparingly throughout them. (?) indicates cell nests, which render the diagnosis of squamous cell car- 
cinoma fairly easy; (k) is a stroma of the growth, very scanty in amount, and consisting of a few spindle- 
shaped cells, but principally of small round cells. At point (I) in the large vessel (c) is a clump of poly- 
morphonuclear leucocytes. The entire picture bears a striking resemblance to angiosarcoma, more 
especially the area enclosed by (h). (Cullen's Cancer of the Uterus, W. B. Saunders Co.). 

22 



338 GYNECOLOGY 

In a benign erosion or eversion of the cervical lips the exposed mucosa 
of the cervical canal, even though hypertrophied, preserves the regular 
arrangement of its folds. In carcinoma the surface is covered with finger- 
like projections which have no regularity of arrangement. The mucous 
membrane in a benign erosion is frequently covered by a clear mucus. The 
finger-like projections of a carcinoma are usually matted together by a blood- 
tinged mucus. If each lip of an everted cervix is caught with a tenaculum and ap- 
proximated at the position of the external os, the eversion of the mucous mem- 
brane will be corrected and the suspicious area will be rolled into the cervical 
canal. An attempt to do this, in the presence of carcinoma, will fail. Palpation of 
an everted mucosa reveals a soft, velvety surface which does not bleed upon 
gentle palpation, while palpation of a carcinomatous surface reveals an in- 
durated, friable tissue, and results in considerable bleeding. Induration of 
the cervical tissue surrounding the suspicious area is more apt to be found in 
carcinoma than in a benign condition. In doubtful cases, by using a small 
curette, it will be found that a carcinomatous area is very friable and may be 
scraped away easily, whereas, in a benign erosion, the tissue does not show 
the same tendency to be broken up and scraped away. In every case, irre- 
spective of the clinical findings, recourse should be had to excision of the 
suspected area and microscopic examination. 

Carcinoma beginning within the cervical canal presents more difficulties 
in the way of an early diagnosis than does carcinoma of the vaginal surface 
of the cervix. In some instances the carcinomatous infiltration extends into 
the substance of the cervix with little external evidence of its existence upon 
the vaginal surface. The cervix, in such cases, is harder than normal, and 
quite likely to be distinctly nodular. If the external os has been opened by a 
laceration or otherwise, the same finger-like projections may be observed 
within the cervical canal. Palpation of the cervix is likely to be followed by 
hemorrhage, and the introduction of a sound will almost invariably produce 
bleeding. By the introduction of a curette within the cervical canal it can 
be determined that the tissue is more friable than normal, and it may be 
possible, without using much force, to excavate an area of some size about 
the cervical canal, the tissue coming away in small pieces, like hard cheese. 

Fortunately, carcinoma originating within the cervical canal is not as 
frequent as carcinoma beginning upon the vaginal surface, and as carcinoma 
of the cervix is usually found in a lacerated cervix, the cervical canal is more 
accessible than in a nulliparous woman, or if no laceration existed. In 
every doubtful case recourse must be had immediately to curettement and ex- 
cision of a portion of the cervical lips, with subsequent microscopic examination. 
Carcinoma of the cervix in the early stage may appear as a small ulcer. 
Ulceration and excavation of a carcinomatous area do not occur, as a rule, 
except in well-developed cases, but occasionally a beginning new growth 
may appear as a small ulcer with indurated base and irregular margins 
bleeding freely upon palpation. Unless it is very superficial an actual ulcera- 
tion of the cervix is commonly malignant. 

The clinical forms of early carcinoma above described may be confused with 



MALIGNANT TUMORS OF THE UTERUS 339 

sarcoma, syphilis, or tuberculosis of the cervix The distinction between them 
can be made positively only by means of a microscopic examinaton. 

Cervical polyps and submucous pedunculated myomata projecting from 
the external os may be mistaken at first sight for cervical carcinoma. A 
careful examination, however, will show at once that the tumors lie within 
the cervical canal and are attached by a pedicle to a point above the internal 
os. As cervical polyps not infrequently undergo malignant degeneration, 
and as 9 per cent, of submucous myomata become sarcomatous, the indica- 
tion in both instances is immediate operation — avulsion and curettement — 
and microscopic examination of the specimens. 

Treatment. — The treatment of carcinoma of the cervix, to be of any avail, 
must be carried out, as a rule, in the early stage. If a carcinoma has over- 
spread the limits of the cervix, the case is hopeless, with few exceptions, 
whether treated by operation or otherwise. Even in some very early 
cases, by the time the patient is exposed to surgical treatment, metastasis to 
some of the pelvic glands has occurred, and operation does not permanently 
cure. It is, therefore, of the utmost importance that cases should be recognized 
at the earliest possible moment. 

The operation for carcinoma of the cervix consists of a panhysterectomy 
in which the entire uterus and the adnexa are removed, together with the 
vaginal vault, and the paracervical and the upper paravaginal connective tissue 
(Fig. 344). In addition to the removal of these structures, in certain cases 
it will be found advisable to remove enlarged pelvic lymph-glands ; as a rule, 
however, if there is any glandular involvement, the disease will return, no 
matter how extensive the operation. The reason for adopting as wide an 
excision of the diseased cervix as possible is that a carcinoma of the cervix 
frequently has microscopic extensions about it which are not recognizable 
grossly, so that, although macroscopically the disease may appear strictly 
limited to the cervix, there may be some small metastases in the structures 
surrounding it. For that reason the parts mentioned are removed with the 
uterus and the adnexa. 

This is the most serious operation which the gynecologist is called upon 
to perform, the danger arising, in part, from the extensive dissection which 
is necessary, and which imperils the integrity of such structures as the 
rectum, the bladder, and the ureters. Furthermore, carcinoma is frequently 
the abode of the streptococcus, and the cellular tissue of the pelvis, exposed 
during operation, is a favorable nidus for the growth and extension of a 
streptococcus inflammation. Another remote danger which obtains in a 
radical operation for carcinoma is that pieces of carcinomatous tissue which 
are broken off during the operation may be implanted in the operative area 
and subsequently developed there. 

For all these reasons, certain steps are taken to sterilize the carcino- 
matous area, as far as possible, before operation, and to prevent the carcino- 
matous tissue itself from coming in contact with the operative field. 

In stout women, or in those in whom, for general reasons, an extensive 
abdominal operation w 7 ould be either very dangerous or very difficult, a 



340 GYNECOLOGY 

vaginal hysterectomy may be substituted for the abdominal operation. This 
may be aided by what is known as a paravaginal incision (Fig. 346) if the 
perineum is rigid, or done without it if the patient has a roomy vaginal 
introitus and the cervix is easily exposed. The preparatory treatment is the 
same for all forms of operation. Under nitrous oxide-oxygen anaesthesia, 
all friable tissue in the carcinomatous area should be removed, and the base 
of the excavation remaining cauterized, with a thermo- or electric cautery. 

If an abdominal hysterectomy is to be performed, the vagina is then 
thoroughly washed out with a solution of bichloride, 1 : 2000, and packed with 
bichloride gauze. 

In the event of a vaginal hysterectomy, after cauterizing the carcinomatous 
area and using the cautery, the vaginal wall is circumcised a short distance 
below the cervix, and a cuff of vaginal tissue turned over the projecting cer- 
vix and united with sutures ; in this way the carcinoma is effectually closed 
off from the operative field (see also Chapter XL for the use of radium in the 
preparatory treatment). 

Prognosis. — The prognosis in carcinoma of the cervix is bad, unless the 
case is discovered in its incipiency. At the present time scarcely more than 
40 per cent, of cases seeking surgical advice are operable — that is to say, are 
suitable for a radical operation, with the hope of removing all the carcino- 
matous disease. European operators give an average operability of 65 per 
cent. ; American figures show only 35 per cent, of carcinomas in an operable 
condition. In nearly 60 per cent, of carcinomas a radical operation is impos- 
sible. In untreated cases death usually results in from twelve to 
eighteen months. 

The best results in the treatment of carcinoma of the cervix show 20 to 
25 per cent, of cures after five years; in other words, 20 to 25 out of 100 
women with carcinoma of the cervix applying for treatment were cured by 
the radical operation. Of the cases which survived the operation, 45 to 55 
per cent, remained cured for more than five years. These statistics may be 
improved by constant watchfulness on the part of the physician in order 
to detect carcinoma in its earliest stage. For this reason, in all suspicious 
cases, the physician should satisfy himself as to the true nature of the affec- 
tion by at once preparing sections for histological examination. 

The Question of Operability. — What is there to guide the surgeon in 
determining which cases are operable and which are inoperable? As a rule, 
when the carcinomatous area has not encroached upon the vaginal vault, or 
is separated from it by a rim of healthy tissue, and there is no fixation of the 
cervix, or induration at the base of the broad ligaments, the carcinoma is 
limited, and there is good hope of removing it by a radical operation ; such 
cases are operable. 

If the carcinoma has destroyed the cervix, or involved its entire extent, 
or spread to the vaginal vault, and if, in addition, the bases of the broad 
ligaments are indurated, and the uterus is fixed, such a case is not amenable 
to the radical operation and may be classed as inoperable. There are certain 
border-line cases in which it will be impossible to say, without an examina- 



MALIGNANT TUMORS OF THE UTERUS 341 

tion under anaesthesia, or even without an exploratory laparotomy, whether there 
is any hope of curing the patient by a radical operation. Induration along 
the sides of the cervix is not always due to extension of the carcinomatous 
process, but may be simply an inflammatory reaction and infiltration. On 
the other hand, carcinoma may have extended beyond the cervix into the 
broad ligaments without giving rise to much induration, or it may have 
given glandular metastasis before any induration or fixation of the uterus, 
or broad ligaments, is demonstrable. 

If one is convinced that the carcinoma has extended beyond the con- 
fines of the cervix or there are any glandular enlargements, it is good practice to 
take the position that the case is hopeless, unless it can be influenced by 
radium and that a radical operation is unjustifiable. In some cases in which 
one is in doubt, an exploratory incision may be made and one may decide by what 
he finds whether to go ahead with the radical plan or not. Cystoscopic exami- 
nation is sometimes of considerable value in determining whether there is 
involvement of the bladder. Cases in which the bladder wall is involved 
almost invariably show bullous oedema and some retraction or contraction 
of the vesical base. 

Treatment of Inoperable Cases. — A new hope may be offered to patients 
suffering with inoperable cancer in the use of radium. If this precious 
element is available, it gives the best promise of relief and sometimes causes 
the tumor to disappear even in advanced cases. Our experience with radium 
is still too recent to speak much of " cures." All we can say now is that in 
some patients after the use of radium the growth disappears and the patients 
are free from symptoms — in the oldest case on record for a period of seven 
years. An application of radium is the least disturbing and painful of any 
method of healing inoperable cases. All that is required is to place the 
radium in the diseased area and leave it there for a certain number of hours. 
(For the statistics, dose, and technic, see Radium and Rontgen Ray Therapy, 
Chapter XL.) 

If radium is not available, then the cold cautery method of Percy should 
be used. This method depends upon the assumption, apparently a fact, that 
a certain degree of heat, short of scorching or burning, will cause the disin- 
tegration of cancer cells while it does not exert a deleterious influence on 
normal tissue. Percy has devised instruments and elaborated the technic 
of this method of treatment. The principle of his operation is to thrust a 
" cold " cautery iron into the midst of the carcinomatous area and then by 
gradual radiation to influence not only the cancer cells immediately in con- 
tact with the iron, but also those at a distance. This requires time, and it is 
not unusual to leave the iron in position for two hours. In addition to 
cautery irons Percy has devised various water-cooled specula, which are 
used for the protection of the surrounding areas. 

Combined with the cold cautery the ligation of the arteries which supply 
the uterus and pelvic viscera with blood has a further favorable influence. 
When the blood supply is shut off from the diseased areas they are more 



342 GYNECOLOGY 

inclined to disintegration. To this end, as a preliminary to the application 
of the " cold cautery," the internal iliac, ovarian, and round ligament arteries 
are tied with non-absorbable ligatures. 

This method is not devoid of danger. Percy has recently published his 
mortality rate which shows that there have been deaths directly following 
the use of his plan. It must be remembered, however, that all such cases 
are poor operative risks and that if let alone death would be inevitable. 
(See technic of Percy method, page 356.) 

If neither radium nor the Percy method is available, then the hope of a 
cure mUst be abandoned, but the relief of certain symptoms, such as fetid 
discharge, hemorrhage, and pain may be secured by a very thorough curette- 
ment of the carcinomatous area and subsequent cauterization ; for this 
either the actual cautery or a chemical solution, such as saturated chloride 
of zinc, 10 per cent, formalin, or pure acetone may be employed. The appli- 
cation should be made to the carcinomatous crater by means of small 
pledgets of cotton which have been pressed out of the solution. The 
vaginal wall and the surrounding healthy tissue -should be protected by a 
thick application of boric ointment. The cotton pledgets are removed at 
the end of forty-eight hours, after which douches of permanganate of 
potassium, 1 : 5000, or lysol, T /\ of 1 per cent., may be given to keep the 
parts clean and reduce the odor. 

For the relief of pain an opiate will ultimately be required. It is best to 
begin with codeine or heroin and later use morphine itself. 

Recurrence of Carcinoma after Operation. — Recurrence of carcinoma fol- 
lowing radical operations for the removal of the uterus is found in approxi- 
mately 45 per cent, of carcinoma of the cervix. The majority of the recurrences 
take place during the first year. Recurrence may be due to implantation metas- 
tasis or the incomplete removal of the carcinomatous tissue, especially in the 
vaginal vault, parametrium, and the lymph-glands. Involvement of the para- 
metrium recognizable at the time of the operation has been followed by 
recurrence in many cases. 

Clinical indications of a recurrence are beginning cachexia with persistent 
and localized pain. In the majority of cases the recurrence takes place in the 
hypogastric or iliac lymph-glands. These form an irregular mass spread out 
upon the surface of the pelvic bones, often best palpable through the rectum. 
Recurrence in some instances may not take place until after the assumed 
limit of cure of five years has elapsed. 

A decrease in the frequency of recurrence is dependent upon earlier recog- 
nition and operative treatment, as well as perfection in the technic of 
the operation. 

CARCINOMA OF THE BODY OF THE UTERUS 

Pathology .—Carcinoma of the body of the uterus, as a rule, occurs later 
in life than carcinoma of the cervix. It is even more insidious than cervical 
cancer, and affects women who have not borne children as much as those 



MALIGNANT TUMORS OF THE UTERUS 



345 



who have. Fibroid tumor of the uterus is complicated by cancer of the 
uterine body in 1.54 per cent, of the cases. Stone has called attention to 
what he terms precancerous changes in the uterus. Under this designa- 
tion he includes, in addition to myomata, leucoplakia, uterine polyps, and 
glandular hypertrophy. Although usually of the glandular type, springing 
from the cylindrical epithelium of the endometrial surface, or the glands 
(Figs. 337 and 338), it also may be, though rarely, of the squamous-celled 
variety, the surface epithelium having undergone a metaplastic change be- 
fore the beginning of the carcinoma. 

Carcinoma of the body of the uterus has a tendency to invade the uterine 
wall and to extend through- 
out the entire endometrium. 
In the late stage it may per- 
forate the wall of the uterus 
and involve the peritoneal 
surface or the parametrium, 
or it may extend down be- 
vond the confines of the in- 
ternal os and involve the 
cervix. It usually requires 
some time before this degree 
of extension takes place. 
Carcinoma of the body of 
the uterus has been regarded 
as little disposed to give 
metastasis, except in the late 
stages ; according to Weibel, 
lymphatic involvement i s 
more frequent and when it 
occurs the metastasis is usu- 
ally to the lumbar and iliac 
glands, or general metas- 
tasis may take place. Metas- 
tasis of carcinoma of the 
body of the uterus, in late 
cases, may also invade the 
inguinal glands through the lymphatics of the round ligaments. The 
adnexa are sometimes the seat of metastasis, even when the uterus is small 
and the carcinoma not very extensive. The adnexal lesion may sometimes 
overshadow the uterine lesion in its clinical manifestations. 

Symptoms. — There are no pathognomic symptoms of cancer of the 
fundus. The most frequent early symptom is irregular hemorrhage or a 
leucorrhceal discharge. The hemorrhage is intermenstrual, and varies from a 
mere show to a brisk hemorrhage. It is brought on by exertion or by some 
slight jolting or movement of the uterus. At first the hemorrhage may be 
regarded as an increase of the menstrual flow incident to the menopause. 
Very often the bleeding begins months or years after the menses have 
ceased ; it is then a striking symptom and likely to attract attention. 




Fig. 337. — Early carcinoma of the endometrium. Diagnosed 
from curettings. (Stetson Hospital.) 



344 



GYNECOLOGY 



The leucorrhoeal discharge is commonly thin, milky, and foul-smelling, 
and may suddenly appear as something entirely new, or gradually show 
itself as an exaggeration of a previously existing leucorrhcea. If hemor- 
rhage and the leucorrhceal discharge begin after a woman has ceased 
to menstruate and has presumably passed the menopause, they are 
especially significant, and in a large majority of cases are indicative of 
malignant disease. 



/% 




»*y5 ''•£. 




Fig. 338. — Advanced carcinoma of the endometrium and small interstitial myoma. The uterine 
cavity was filled with a necrotic putrid mass. The walls of the uterus at the area of the attach- 
ment of the tumor were destroyed almost to the peritoneal coat. (Gynecological Laboratory, U. of P.) 

In the later stages, when the carcinoma has involved a good part of the 
uterine wall (Fig. 338), and necrosis of the carcinomatous tissue has begun, 
to those symptoms already mentioned will be added a more or less constant 
putrid discharge, and the symptom-complex known as cachexia. 

Diagnosis. — A positive diagnosis is not possible in the early stages without 
the aid of digital or instrumental intrauterine exploration, supplemented in early 
or doubtful cases by a microscopic examination of endometrial scrapings. 
There may be very little enlargement of the uterus in a case of early 
carcinoma. Perhaps in a majority of early cases the uterus is not enlarged, 



MALIGNANT TUMORS OF THE UTERUS 345 

the disease frequently beginning after the menopause in women who have 
not borne children, so that the uterus may be entirely normal in size, or even 
small. Dilatation of the cervix, with curettement, is the diagnostic means 
par excellence. 

The practised hand will often obtain positive information from curettage. 
This may reveal a roughness or thickness of the endometrium; the amount 
of tissue removed is commonly greatly in excess of that in a case of simple 
hypertrophy of the endometrium. It is whitish, like old cheese, in appear- 
ance, quite friable, and comes away in disconnected pieces rather than in 
long strips or ribbons. In any doubtful case the operator must wait until a 
microscopic examination of the curetted particles can be made. Every case 
diagnosed clinically as carcinoma must be confirmed by histologic examina- 
tion. Serological and biological methods proposed in recent years for the 
diagnosis of carcinoma have not proved specific in a sufficient degree of 
accuracy to be accepted. 

Treatment. — The treatment of carcinoma of the body of the uterus con- 
sists of panhysterectomy. Early cases, in which the entire uterus and the 
tubes and ovaries are removed, will almost invariably remain permanently 
cured. Even some of the later cases in which the carcinoma has advanced, 
almost but not entirely, through the muscular wall of the uterus, will be 
permanently cured by complete hysterectomy. Fortunately, in cancer of the 
fundus metastasis occurs later than in cancer of the cervix, and the disease 
does not ea+ its way through the uterine wall until far advanced. 

Complete hysterectomy for cancer of the fundus may be done by the 
abdominal or by the vaginal route. There is no need for a wide resection of 
the vaginal vault or the base of the broad ligaments. The abdominal is 
preferable to the vaginal route unless the woman is excessively stout. In 
nulliparae a paravaginal incision may be used to facilitate vaginal hysterec- 
tomy. If the uterine fundus is enlarged to any considerable extent, if it 
contains a fibroid tumor or tumors in addition to the cancer, if there are any 
adnexal complications, or if there are any intestinal or intra-abdominal 
symptoms which make abdominal exploration advisable, the vaginal route 
is unsatisfactory. 

The treatment preparatory to hysterectomy for carcinoma of the 'fundus 
should consist of an application of the tincture of iodine to the interior of 
the uterus, the introduction of a tight uterine pack, and the closure of the 
cervix with several sutures. This preparatory treatment should immedi- 
ately precede the radical operation, and is for the purpose of disinfecting and 
shutting off the carcinomatous growth from the operative area. 

Advanced cases of carcinoma of the fundus which are not amenable to 
radical operation may be exposed to radium or the Rontgen ray (see 
Chapter XL). 

Prognosis. — The prognosis of carcinoma of the fundus is much better 
than that of carcinoma of the cervix. While statistics vary and depend 
upon the stage of the disease and the technic of the operator, about 75 per 
cent, are cured. 



346 GYNECOLOGY 

SARCOMA OF THE UTERUS 

Pathology. — Sarcoma may originate in the connective tissue of the cer- 
vix, or in the body of the uterus, or it may represent the transformation of a 
myoma of the uterus into a myosarcoma. Sarcoma of the cervix is rare, 
being most frequently found in infants or in young children, and likewise 
primary sarcoma of the body of the uterus is very rare ; in a series of 3000 
operative cases at the University Hospital, it has only occurred twice. The 
most frequent form of sarcoma of the uterus is the myosarcoma, a degen- 
eration of the ordinary myoma. Primary sarcoma of the uterus may be of 
the round or spindle-celled type. Metastasis may take place to various 
organs, notably the lungs, liver, ovaries, and intestinal tract. 

Symptoms. — Sarcoma of the cervix occurring in young children first 
draws attention to itself by the hemorrhage which it occasions and by the 
appearance of a purplish-red, grape-like mass at the vulvar orifice. It begins 
upon either the cervix or the vaginal vault, grows very rapidly, and even 
though it is removed by a radical operation, very few cases recover. Sar- 
Qoma in the adult, whether of the cervix or the body of the uterus, differs in 
no wise symptomatically from carcinoma. 

Diagnosis. — The diagnosis of sarcoma of the cervix is justified clinically 
when a tumor having the characteristics mentioned appears in a young child 
or infant. A microscopic examination should be made for verification. In 
the adult, sarcoma of the cervix can only be positively distinguished from 
carcinoma by a microscopic examination, the symptoms, subjective and 
physical, being practically the same as those of carcinoma. Sarcoma of the 
fundus also exhibits exactly the same symptoms as carcinoma, and can be distin- 
guished therefrom only by a histologic examination of scrapings. 

Treatment. — Sarcoma developing in a myoma is usually not detected 
until a histological examination is made of the tumor after removal. 
It may, however, be suspected in a growth which has been quiescent 
for some time and then begins to increase rapidly in size; such a degen- 
eration is especially frequent in submucous fibroids. The treatment of 
sarcoma of the uterus is the same as that of carcinoma. It must be detected 
at an early stage and subjected to a radical operation to ensure a 
favorable outcome. 

CHORIOEPITHELIOMA 

Pathology. — As its name implies, chorioepithelioma is a new growth 
originating in the epithelium of the chorion. It is the result of an irregular 
and abnormal proliferation of the chorion epithelium. The chorion epithe- 
lium normally possesses a destructive action which, early in pregnancy, 
assists in the formation of the placenta. As soon as the placenta is formed 
the destructive activity of the chorion epithelium ceases. This is almost 
certainly the result of specific antagonistic substances (syncytiolysins) cir- 
culating in the blood. Under certain circumstances the inhibitory action of 
the antibodies is too weak and the impulse of the chorion epithelium to 






MALIGNANT TUMORS OF THE UTERUS 



347 



proliferate and destroy is unusually strong; it keeps on proliferating and 
destroying, becomes irregular and unlimited in growth, and constitutes a 
chorioepithelioma. Even after the development of a tumor mass the resist- 
ance of the individual may be so increased that the proliferating and de- 
structive powers of the tumor become neutralized and it shrinks and dis- 
appears. If this fortunate increase in resistance does not occur, the growth 
is rapidly fatal. 

While chorioepithelioma sometimes makes its appearance after normal 
pregnancy and labor (growing from masses of chorion epithelium embedded 
in the wall of the uterus at the placental site), as a rule, it follows an abor- 
tion. In this the feet us and the placenta may have exhibited no abnormali- 
ties ; yet there often exists the evidence of some disease of the placenta ; 
the most frequent being hydatidiform mole. While hydatidiform mole is by 
no means invariably followed by a chorioepithelioma, it certainly predis- 





FlG. 340. — Metastases of chorioepithelioma in kidney, liver, lung and pancreas. (University Hospital.) 



poses to the latter as can be gathered from the fact that about half of the 
cases of chorioepithelioma follow hydatidiform mole. 

The proliferating chorioepithelioma eats its way into the muscle of the 
uterus, eroding blood-vessels, causing interstitial hemorrhage between the 
muscle fibers, and by its proliferation producing interstitial hsematomata, 
with a definite enlargement, softening, and altered appearance of the af- 
fected part (Fig. 339, frontispiece). The proliferating cells quickly gain access 
to the blood stream and are deported to all parts of the body — brain, lungs, liver, 
kidneys, spleen, etc., where metastatic growths are set up having the same 
destructive properties as the original tumor (Fig. 340). Metastasis is fol- 
lowed shortly by death. 

The original chorioepithelioma is always at the site of the chorion or 
placenta, and therefore in the uterus (uterine gestation) or in the tube 
(tubal gestation). In a few instances the original tumor has been cast off or 



348 GYNECOLOGY 

curetted away while the first recognized evidence of the disease has been a 
metastatic deposit. This is spoken of as " a chorioepithelioma outside the 
placental site ; " it has been found most often in the vault of the vagina of 
which the rich venous plexuses favor metastasis. 

It is interesting to note that in a fairly large number of cases of chorio- 
epithelioma, as well as of hydatidiform mole, bilateral lutein-cell cystomata 
of the ovaries have been found. The size of such cystic ovaries varies ; they 
have been observed as large as a foetal head. The cause of lutein cysts and 
the relationship between them and the chorioepithelial diseases are as 
yet unexplained. 

Symptoms. — The symptoms of chorioepithelioma are hemorrhage and 
tumor. These develop shortly after the expulsion of an hydatidiform mole, 
abortion, or labor at term. Exceptionally a much longer time (several 
years) may intervene, or the disease may make its appearance in association 
with hydatidiform mole, even before the mole is discharged. Hemorrhage 
occurring several weeks after the uterus has discharged its pregnant con- 
tent is always suggestive of hydatidiform mole. After hydatidiform mole 
symptoms such as described are especially likely to mean a chorioepi- 
thelioma. In a few cases a vaginal or a labial nodule or metastasis has 
attracted the attention of the patient to her condition. Sometimes she may 
be conscious of an enlargement of the uterus — abdominal tumor. The pa- 
tient becomes rapidly anaemic ; toxaemia from infection and necrosis of the 
tumor mass develop, evidences of metastasis — thoracic pain, cough, rusty 
sputum, etc. — appear, and the patient rapidly succumbs. Death may occur 
within a few months of the first appearance of symptoms. 

Diagnosis. — Once the suspicion of chorioepithelioma is entertained, ex- 
ploration of the uterus with diagnostic curettage and microscopic examina- 
tion is immediately demanded. Metastatic nodules in the vagina and about 
the vulva which appear like varicosities or haematomata should be excised. 
The microscopic appearance of the uterine scrapings should be considered 
in connection with, the clinical evidence. A tumor mass plus the character- 
istic appearance of chorioepithelioma is diagnostic. But the histological 
appearance of chorioepithelioma is so little different from the picture that 
might be furnished by a small portion of placenta and decidua attached to 
the uterine wall, that both clinical and microscopic evidence must be taken 
in making the diagnosis positive. Tissue which is taken from any other 
locality than the placental site and exhibits the histological appearance of 
chorioepithelioma is, of course, positively diagnostic. 

Prognosis. — The prognosis, as a rule, is bad, but in the individual case it 
depends upon the stage at which the disease is detected. Even the incom- 
plete removal of the tumor has been followed by recovery. When primary 
in the uterus the removal of the tumor has been followed by the spontaneous 
disappearance of metastatic growths. About 80 per cent, of cases of chorio- 
epithelioma die within six months after the appearance of the tumor. In 
188 cases collected from the literature with 99 radical operations, Teacher 
reports 63.6 per cent, of recoveries. 



MALIGNANT TUMORS OF THE UTERUS 



349 



Treatment. — For chorioepithelioma of the uterus immediate panhyster- 
ectomy is indicated. The broad ligament should be excised to as great an 
extent as possible in order to get rid of veins containing metastatic par- 
ticles. Vaginal and labial nodes should be taken out with a wide marg-in 
of healthy tissue. Radium may be used when it is evident that the dis- 
eased tissue has not been entirely removed, or the case has passed beyond 
the bounds of operability, or when there is a recurrence after operation. 



OPERATIVE TECH NIC 

Panhysterectomy for Malignant Tumors of the Cervix (Wertheim). — In 

performing a panhysterectomy for a malignant tumor, the diseased area 
must be prepared in such a manner as to get rid of the friable cancerous 
tissue, and to kill, as far as feasible, 
any bacteria which have found lodg- 
ment there. To accomplish this, the 
patient is placed in the dorsal position \ 

and, after the usual preliminaries, the 
diseased cervix is thoroughly cauter- 
ized, removing the exuberant 
carcinomatous tissue. The anterior 
and posterior lips of the cervix are 
united by catgut sutures over the car- 
cinomatous area, if possible. Unless 
the disease is limited in extent, this 
cannot be done. The vagina is thor- 
oughly washed with sterile water and 
bichloride solution, and a wet bichlo- 
ride gauze pack is left in the vagina. 
The patient is then placed in the cus- 
tomary position for laparotomy, and 
after the usual preparations have been 
completed, a median incision is made 
from near the umbilicus to the symphysis, and the intestines are packed of! 
from the pelvic cavity with a double layer of pads. The incision should be 
long enough to give ready access to the pelvis, and the patient should lie in 
an exaggerated Trendelenburg position while the pads are being introduced 
so as to isolate and expose the operative area to the greatest possible extent. 
The fundus of the uterus is now grasped with a forceps in order to afford a 
point of fixation, and the hysterectomy is started on one side. The infundi- 
bulo-pelvic and round ligaments are ligated close to the brim of the pelvis, 
and divided, reflex bleeding being prevented by forceps applied along the 
sides of the uterus. The broad ligament is divided to the outer side of the 
ovary and tube, and the anterior and posterior leaflets separated by blunt 
dissection down to the base of the broad ligament. The ureter adhering 
to the posterior leaflet, a little above and to the outer side of the utero- 
sacral ligament, is now sought for. Some practice is required for 
the orientation of the ureter, but usually it can be found by palpation 
(Fig. 341) ; in very fat subjects this is facilitated by the preparatory intro- 




Fig. 34 T - — Panhysterectomy for carcinoma. After 
ligation of the ovarian (shown in picture) and round 
ligament arteries the leaves of the broad ligament 
are separated and the ureter recognized by rolling it 
between the thumb and first finger (right side). 



350 



GYNECOLOGY 



duction of a ureteral catheter. After locating the ureter a loop of catgut is 
thrown about it (Fig. 342), and the free ends of the catgut knotted and left 
lying outside of the celiotomy incision. The incision through the anterior 
surface of the broad ligament is now continued through the vesical reflection 
of the peritoneum to the opposite side, where a similar dissection of the 
ureters is carried out. After exposing the ureters care should be taken to 
protect them, handling them as little as possible to avoid traumatism. 




Fig. 342. — Passing loop of catgut about ureter; facilitates orientation during the operation. 



By means of the catgut loops, the ureters may easily be exposed when 
desirable during the course of the operation. The finger is pushed through 
the base of the broad ligament from behind forward, along the upper 
surface of the ureter, picking up the uterine vessels and the cellu- 
lar tissue of the base of the broad ligament; the uterine artery and 
veins are ligated as far out toward the pelvic wall as possible (Fig. 
343)- The same plan is carried out upon the opposite side. Both utero- 
sacral ligaments are ligated and divided about one-quarter of an inch away 



MALIGNANT TUMORS OF THE UTERUS 



351 



\>«sseVs 



from the uterus, and the peritoneal incision on the posterior surface of the 
broad ligament is continued down over the anterior wall of Douglas' pouch 
to the opposite side. The bladder is pushed away from the anterior surface 
of the cervix, at first in the median line, and then at either side at the posi- 
tion of the ureters, so as to expose these structures entirely (Fig. 344). The 
parametrium is then separated from the pelvic wall and floor, on either side, 
the bleeding points being caught with long clamps and tied. This dissection 
is carried down into the cellular tissue surrounding the upper part of the 
vagina. At this stage of the operation the uterus with the adnexa, broad 
ligaments, parametrium, upper part of the vagina, and paracolpium, have 
been freed from the surrounding structures and are connected with the pelvis 
by the vaginal attachment only. The bichloride gauze pack in the vagina is 
now removed, and the vagina irrigated 
by an assistant. One right-angle clamp 
is applied to the vagina below the cervix, 
at least a half inch below the diseased 
area, as can be determined by palpation ; 
another clamp is placed a quarter of an 
inch below the first (Fig. 345). The 
vagina is divided between the clamps by 
means of a cautery knife, and the dis- 
eased uterus with its attached broad liga- 
ment, cellular tissue, and vaginal cuff, is 
removed. Sutures are passed above the 
second clamp which close the vagina and 
insure hsemostasis. Such diseased glands 
remaining in the base of the pelvis as are 
palpable are dissected out. Bleeding 
points are caught with forceps and 
ligated, and the raw surfaces which have 
been exposed are covered with the vesi- 
cal reflection of the peritoneum. Where the oozing from the divided capil- 
lary vessels is free and cannot be entirely controlled, a gauze wick may 
be placed to drain the subperitoneal space through the middle of the vaginal 
vault, but this drain should not be allowed to come in contact with 
the ureters. 

Vaginal Hysterectomy for Malignant Tumors of the Cervix (Simple). — 
After the customary preliminary disinfection of the perineum and vagina, 
and the preparation of the carcinomatous area, the anterior and posterior 
lips of the cervix are united by sutures in such a way as to cover the cancer- 
ous crater, or, if that is impossible, the carcinomatous crater is packed with 
bichloride gauze and sewn over with sutures ; or the vaginal fornices are 
circumcised about an inch from their reflexion to the cervix, and a cuff is 
turned over the diseased area. The bladder is separated from the anterior 
surface of the uterus, pushed up, and the vesicouterine fold of peritoneum 
incised. Douglas' pouch is opened by a posterior incision, the anterior and 
posterior incisions not meeting, but being separated by tissue at the sides 
of the cervix which contains the uterine vessels. The fundus of the uterus 




FlG. 343. — Ligation of uterine vessels, 
isolated on finger. 



Vessels 



352 



GYNECOLOGY 



is pulled into the vagina, the infundibulo-pelvic and round ligaments 
ligated on either side, provisional clamps placed along the borders of the 
uterus to prevent reflux bleeding, and the broad ligaments divided down to 
about the position of the uterine arteries (Fig. 347). At this point the operator 
makes sure that the base of the bladder and the ureters on either side have been 
separated from the uterus and are held out of the way by means of a long 
retractor. The base of the broad ligament is then ligated close to the uterus 




Fig. 344. — Dissection of bladder and ureters. 



on either side, and the attachments which remain between the uterus 
and the base of the broad ligaments and the vagina are divided. The 
stump of the broad ligament on either side is drawn gently into the vault 
of the vagina and fixed in its corresponding angle by an extra suture. The 
anterior and the posterior peritoneal borders are united in the median line 
between the stumps of the broad ligaments. The vaginal vault is closed by 
interrupted or continuous sutures. 

Vaginal Hysterectomy for Malignant Tumors of the Cervix with Para- 



MALIGNANT TUMORS OF THE UTERUS 



353 



vaginal Incision. — Vaginal hysterectomy, according to the technic of 
Schauta, requires a very free exposure of the vaginal vault. As this is only 
practicable in relaxed multipara, he secures good exposure and easy access 
in other cases by dividing the levator ani muscle in one or both vaginal 
sulci (Fig. 346). The carcinomatous area is prepared by cauterization, 
and a cuff of the vaginal fornix is sewn over the diseased area. 
The operator separates the bladder from the cervix, and by careful dissec- 
tion exposes the ureter, holds it out of the way, and isolates and divides the 



\iOw£. ^cj* 




Fig. 345. — Application of clamps to vaginal wall. 

uterine artery well out toward the pelvic wall. The fundus of the uterus is 
then anteverted through the vesico-uterine incision, and the ovarian and 
round ligament vessels securely ligated. The uterus is removed and the 
operation completed as has been described under simple vaginal hyster- 
ectomy. Drainage is usually employed. 

Destructive Cauterization. — The carcinomatous tissue is destroyed with 
a cautery iron heated to a cherry red. A cutting blade is used at first, in 
order to remove exuberant masses. Thereafter, a blunt iron is passed re- 
peatedly over the carcinomatous area, thoroughly destroying all gross 
23 



354 



GYNECOLOGY 



vestiges of the disease. The prognosis depends, to some extent, upon the 
thoroughness with which this is done. Care must be taken lest perforation 
of adjacent organs — bladder, rectum — take place, or the peritoneal cavity 
be invaded. The burned area is then packed with pledgets of cotton satur- 
ated with acetone, and the vaginal vault and the vagina are filled with 
gauze impregnated with sterile oil. 

High Amputation for Malignant Tumors of the Cervix with a Cautery 
Knife. — In very early cancers of the vaginal cervix (squamous-celled car- 
cinoma, epithelioma), which are limited to the vicinity of the external os, 
high amputation of the cervical lips with a cautery knife may be as 

effectual as any form of opera- 
t i o n . After a preparatory 
cauterization, the cervix is 
firmly grasped with a diverg- 
ing volsellum in the canal and 
pulled down, and with a cau- 
tery knife, heated to a cherry 
red, the attachments of the 
vaginal fornices to the cervix, 
well outside the limits of the 
new growth, are slowly divided. 
The bladder is separated from 
the anterior surface of the cer- 
vix as far as possible, and the 
vaginal fornices are pushed 
away posteriorly, up to the 
peritoneal reflection of Doug- 
las' pouch. The lips of the 
cervix are now amputated by 
means of a cautery knife, and 
the cervical canal thoroughly 
cauterized. By guiding the 
knife blade upward and in- 
ward, a large amount of the 
uterine body may be included 
in the amputation. The wound 
is allowed to heal by granula- 
tion. In using the cautery knife in vascular areas care should be taken that it is 
cold when applied to the tissues and heated to a cherry red when in action; it 
should be allowed to cool before changing its position or reapplying. The reason 
for this is that if the knife, though heated only to a dull red, be applied to 
parts at all vascular more or less hemorrhage will follow, whereas if the 
cool platinum blade is already in contact with the tissues as the current is 
being transformed into heat, the vessels are shrunken or closed before they 
are severed. 

Percy Method.— Percy objects strongly to his treatment being classed 
as a cauterization because when the word cautery is used the average per- 
son gets an entirely wrong impression of the object to be attained. To the 




L 



Fig. 346. — Paravaginal incisions (after Ward, Surgery, Gyne- 
cology and Obstetrics). 



MALIGNANT TUMORS OF THE UTERUS 



355 



novice in the- application of this technic, one of the surprises is the slowness 
with which the heat penetrates the cancer mass ; it requires from twenty 
to forty minutes before an appreciable degree of heat is felt in the involved 
organs. This frequently leads the operator, unfamiliar with the proper way 
of applying the technic, to turn on more heat, which merely causes charring 



■^ 




D-road li yam eat 



•-x- 



Fig. 347. — Vaginal hysterectomy. Application of clamps to broad ligament (Mayo, 
Surgery, Gynecology and Obstetrics). 

of the tissues and the formation of a carbon core which does not transmit the 
heat well; then more heat is turned on until the degree of heat reaches a 
dangerous point. In order to illustrate the proper degree of heat to be used, 
Percy states that when cotton is wrapped around the heated cautery, it 
should not even change color. The curette should never be used before apply- 



356 GYNECOLOGY 

ing the treatment, even to get a portion of the diseased tissue for diagnostic 
purposes ; when the tissues are thoroughly permeated by the heat, the cells 
are fixed in such a way as to become immediately available for sectioning 
and staining without the use of the usual hardening fluids. At the same 
time, the heat at once seals the lymphatic and blood-vessels, preventing the 
further dissemination of the cancer and mixed infection. In addition, the 
immediate nerve supply is cut off; this explains the freedom from shock 
and local pain which is the rule following this treatment. It is not a part of 
the technic to remove any of the pelvic structures which are the seat of cancer. 
The exception to this statement is that both ovaries are removed; first, to 
limit the blood supply, and secondly, to bring on the menopause where it has 
not yet occurred. If this is not done, a torturing form of menstruation may 
occur for a few periods because of the cervical stenosis which occasionally 
follows the application of the heat. The most distressing class of cases to 
treat are those in which recurrences follow a panhysterectomy, because in 
these there is no exuberant mass to use as kindling to develop heat. When 
recurrence follows a total hysterectomy, it is usually of the infiltrating type 
and the invaded tissues left after the hysterectomy are not of sufficient 
thickness to permit of the development of a degree of heat necessary to kill 
the carcinoma cells. As a cauterizing temperature cannot be regulated it 
has a distressingly destructive effect which will probably obliterate the most 
important part of the urethra or make a hole in the bladder. In order to 
overcome this difficulty caused by lack of tissue in recurrent cases, Percy 
has tried filling the vagina with a tightly bound mass of beef, in which a 
hole has been made with an apple corer for the heating iron. In this way 
he has succeeded very well in irradiating heat through the vaginal walls to a 
degree that is destructive to the cancer cells. 

Technic. — The technic of the treatment as practised by Percy may he 
briefly outlined as follows : The abdomen is opened, the extent of metas- 
tases determined, and the internal iliac arteries ligated, after packing off the 
intestines, or, if this is difficult to do, the uterine arteries are ligated as near 
the pelvic wall as possible. When high degrees of heat are used, late 
hemorrhages are rare, but with the low degrees of heat used in this method, 
they become more frequent. It is an advantage, therefore, to tie off all the 
pelvic blood supply in order to aid in the starvation of the tissues which 
might otherwise become involved in the malignant process. This is accom- 
plished by ligating the internal iliac arteries and removing the ovaries. 
Since doing this, Percy has had no hemorrhages, whereas before this be- 
came a part of his technic, hemorrhages occurred in 2.5 per cent, of his cases, 
usually about two weeks after the operation, and were responsible for the 
death of four patients. The vagina is then dilated and a water-cooled 
speculum inserted. The heating iron is introduced through the speculum to 
the fundus of the uterus and held there until everything abnormal is too hot 
to hold in the hand of the assistant, which is encased in a medium weight 
rubber glove. If the heating iron is moved aimlessly about, no area will 
become sufficiently heated to destroy the carcinoma. After the heat has 
penetrated the uterus to the desired degree, the heating iron is moved to a 
new position, and the procedure repeated. This is continued until all the 



MALIGNANT TUMORS OF THE UTERUS 357 

pelvic tisues are freely movable, the complete seance sometimes lasting sev- 
eral hours ; but during this time the patient requires only the very 
lightest anaesthesia. 

After the treatment there is usually an offensive discharge lasting about 
two weeks, and uterovesical and uterorectal fistulas occasionally result from the 
treatment, but they usually heal spontaneously. At times, however, when the 
fistula is in the vagina, it is a difficult matter to secure closure. In about 
50 per cent, of the cases a reapplication of the heat is necessary. In two 
cases Percy has repeated the treatment five times. The abdomen must be 
opened at each application and the hand inserted in order to determine the 
amount of heat required. Percy insists that a secondary radical operation 
should not be performed even if the case seems to be operable, as nothing 
is to be gained thereby, but, on the contrary, the cicatricial tissue is broken 
down and may be the starting-point of a recurrence, inasmuch as nature's 
defense is removed. " It must be remembered that the majority of the cases 
which Percy has treated are of the utterly hopeless type, most of whom 
have been refused operation by other surgeons, so that a cure in any of them 
is of great significance " (Clark, J. G., " Progressive Medicine," 1916, p. 215). 

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358 GYNECOLOGY 

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Mayo, Wm. J.: "The Cancer Problem." Jour. Lancet, 1915, xxxv, 339. 

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Sanger : " Ueber Deciduome." Cent, f . Gyn., 1889, xiii, 132. 

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called Deciduoma Malignum) and the Occurrence of Chorionephitheliomatous and 
Hydatidiform-mole-like Structures in Tumors of the Testis." Trans. London Obst. 
Soc, 1903, xlv, 256. 

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1913, 135- 
Weibel, W. : " Weitere Beobachtungen liber das Verhalten der Ureteren nach der Erwei- 

terten Abdominalen Karzinomoperation." Zeitsch. f. Gyn. u. Urol., 1913, iv, 138. 
Werder, X. O. : "The Byrne Operation and Its Application in the Radical Treatment of 

Cancer of the Uterus." Amer. Jour, of Obst., 1905, Hi, 700. 
Wertheim : " Die Erweiterte Adominale Operation bei Carcinoma Colli Uteri." Berlin und 

Wien, 191 1. 



CHAPTER XIX 
DISEASES OF THE FALLOPIAN TUBES 

SALPINGITIS 

Etiology. — Inflammation is the most frequent affection of the Fal- 
lopian tubes. Salpingitis is invariably caused by a bacterial infection. 
Mechanical, thermal, or chemical irritation may cause circulatory dis- 
turbance and tissue hypertrophy or atrophy, but not a true inflammation. 
The gonococcus is the organism which is especially prone to attack the tubes. 
Gonorrhoea! salpingitis constitutes a very large part of tubal pathology. 

Other organisms which may produce inflammatory lesions of the tubes 
are the streptococcus, staphylococcus, colon bacillus, and tubercle bacillus ; 
and rarely also the pneumococcus, typhoid bacillus, and ray fungus. The 
infecting organisms reach the tubes (i) by extension upward from the endo- 
metrium along the mucosa (gonorrhoeal endometritis), or (2) by extension 




3 




Fig. 348. — Acute gonorrhceal salpingitis, gross (Norris. Gonorrhoea in Women, 
W. B. Saunders Co.). 

downward from the peritoneal cavity, through the open abdominal ostium 
(peritonitis, enteritis, appendicitis — tubercle bacillus, colon bacillus, strep- 
tococcus) ; (3) by extension from distant foci through the blood stream (tuber- 
culosis — tubercle bacillus ; typhoid fever — typhoid bacillus ; actinomycosis — 
ray fungus) ; or (4) by direct extension through the peritoneal coat from 
adherent and diseased structures (ovaritis, cellulitis, peritonitis — strepto- 
coccus, staphylococcus, colon bacillus, etc.). 

It is possible that streptococcus, staphylococcus, tubercle bacillus, and 
colon bacillus infections may extend along the mucous surface from the 
uterus into the tube, but such is not the rule. This is in direct contrast to 
gonorrhceal infection which almost invariably advances along the mucous 
surfaces. Streptococci, staphylococci, and colon bacilli are most apt to attack 
the tube from infected neighboring or adherent structures. 

In the great majority of cases salpingitis is caused by the gonococcus, 
and next in order of frequency by the streptococcus, staphylococcus, colon 
bacillus, and tubercle bacillus. 

Pathology. — Gonococcus infections attack primarily the mucosa (endo- 
salpingitis) and lead to closure of the abdominal ostium, destruction of the 

359 



360 GYNECOLOGY 

mucous plicae, and distention of the tube with pus ; streptococcus, staphylo- 
coccus, and colon bacillus infections attack primarily the outer serous coat 
(perisalpingitis) and may lead to adhesions, angulation, thickening, and in- 
filtration of the tube wall (interstitial salpingitis), or even to closure of the 
abdominal ostium (hydrosalpinx), but they rarely produce pyosalpinx 
(Figs. 348 and 349). The infections caused by the streptococcus, staphylo- 
coccus, and colon bacillus are usually an extension from diseased and 
neighboring parts (metritis, cellulitis, ovaritis, peritonitis, appendicitis) ; 
the lesion is a perisalpingitis and the involvement of the tube is of secondary 
importance. Next to the gonococcus the tubercle bacillus is the most fre- 
quent cause of suppurative inflammation of the tubal mucosa. Tuberculous 




Fig. 349. — Acute gonorrficeal salpingitis. (Gynecological Laboratorj', U. of P.) 

salpingitis is marked by characteristic lesions which are dealt with in 
Chapter XXX (page 561). 

In gonorrhoeal salpingitis, both tubes are affected in a large majority of 
cases. The disease in one tube, however, may slightly precede the infec- 
tion of the other, so that the pathological change on one side may be fur- 
ther advanced or more marked than on the other side. Streptococcus, 
staphylococcus, and colon bacillus salpingitis are often unilateral. 

Endosalpingitis. — In endosalpingitis the infection attacks the mucosa, 
the folds of which become congested and covered with pus. The tube wall 
becomes cedematous and thickened. The diameter and the length of the tube 
are increased. From a soft, almost impalpable structure it becomes indur- 
ated and well defined. On microscopic examination the stroma of the 
plica is found to be swollen, cedematous, and infiltrated with small round cells, 
polymorphonuclear leucocytes, and plasma cells ; the surface epithelium is 
proliferated, swollen, imperfectly stained, and in many places detached from 
the stroma. The muscle and fibrous tissue of the tube wall are infiltrated 
with leucocytes ; the lumen of the tube is filled with pus. 



DISEASES OF THE FALLOPIAN TUBES 



361 



Perisalpingitis. — In this condition the infection attacks the outer sur- 
face of the tube, which becomes congested and adhesive ; the peritoneum 
loses its glistening appearance, exudate is thrown out which binds the tube 
to neighboring structures, and the ovary and pelvic peritoneum are usually 
coincidently involved. If the amount of exudate is large the abdominal 
ostium of the tube may be occluded. 

Interstitial Salpingitis. — When the infection attacks the wall of the tube 
from within or from without, the condition is described as interstitial sal- 
pingitis. The muscular coats are cedematous and thick; there is a widespread 
infiltration with polymorphonuclear leucocytes ; at certain points minute 




Fig. 350. — Uterus and appendages in extensive pelvic inflammatory disease exposed in the incision. 

foci of suppuration may appear ; later, as the acuteness of the condition sub- 
sides, there may be connective tissue hypertrophy about these minute foci. 
Irregular enlargement of the tube from intramural foci of suppuration is 
most frequent in the isthmic or interstitial part. To this condition the name 
salpingitis isthmica nodosa has been given. The disease may be limited to 
the area of enlargement. The middle and outer parts of the tube may 
appear quite normal. 

End-results of Endosalpingitis. — The formation of pus in gonorrhoeal 
endosalpingitis is free, and except in very mild cases is extruded in greater 
or less amount from the abdominal ostium of the tube upon the surface of 
the pelvic peritoneum. From this there results a localized pelvic peritonitis, 
more or less extensive, with the formation of exudate and inflammatory in- 



362 GYNECOLOGY 

filtration. As the result of the exudate, and the adhesions which form be- 
tween the ostium of the inflamed tube and the pelvic peritoneum, by the 
time the inflammatory symptoms are abating, or even during their progress 
if the case is a severe one, the abdominal ostium of the tube becomes sealed, 
and the pus forming within, being no longer able to escape from the abdom- 
inal ostium, begins to distend the tube itself (Fig. 349). As the process 
goes on, the tubal plicse may be destroyed to a great extent, the only part 
escaping destruction being the bases which are compressed and flattened 
against the wall of the tube by the purulent content, or the individual plicse 
bereft of surface epithelium at certain points, become more or less exten- 




Fig. 351. — Uterus and appendages in extensive pelvic infllrmmatory disease; the adhesions divided, the 
parts mobilized and ready for extirpation. 

sively adherent to each other, leaving between them completely isolated 
gland-like spaces representing remnants of the tube lumen. 

Under rare circumstances the pent-up pus, after reaching a certain 
degree of compression, may be discharged through the uterine end of the 
tube into the cavity of the uterus. But this is not a frequent occurrence, 
for the infiltration of the tubal wall, the fixation and distortion of the tube 
which are incident to the inflammation, and the complicating peritonitis 
with adhesions and exudate, usually block the uterine extremity. 

Pyosalpinx. — When the tube has become distended with pus, the result- 
ing tubal enlargement is known as a pyosalpinx (Fig. 352). The tube by 
this time almost invariably has contracted adhesions to neighboring struc- 
tures, has been pulled out of position, and has become variously distorted in 



DISEASES OF THE FALLOPIAN TUBES 363 

shape. It may vary in size from that of a finger to that of a sausage or a 
sweet potato. The wall may be quite thin when it is simply distended or 
overstretched, or quite thick when it has been invaded by the septic process. 

The changes in the ovary which accompany endosalpingitis are the result 
of, and secondary to, the complicating pelvic peritonitis. The ovary itself 
is not primarily involved. The exudate thrown out by the inflamed peri- 
toneum at first buries the ovary and later leads to adhesion or a permanent 
thickening of the ovarian capsule. A Graafian follicle or a fresh corpus 
luteum may become infected by the exudate and form an abscess. 

If the endosalpingitis has been mild, and the peritoneal involvement 
slight, the inflammatory process may subside without a closure of the ab- 
dominal ostium or the formation of a pyosalpinx. But usually there are 
permanent residua of the disease, such as enlargement and distortion of the 




Pig, 352. — Pyosalpinx and ovanan abscess. (Norris, Gonorrhoea in Women, 
W. B. Saunders Co.) 

tube, adhesions, thickening of the plicae, proliferation of the surface epi- 
thelium, and the formation of little pockets or cystic spaces in the mucosa 
brought about by the coalescence of the tips of neighboring folds. Though 
the gonococcus infection remains latent in the tubal mucosa or the endo- 
metrium, the patient may, and usually does, experience a repetition of the 
acute attacks. Repetition of the attack is usually precipitated by some 
trauma, such as rough examination, coitus, straining at stool, douching, etc. ; 
the activity of the gonococcus is renewed ; pus is again discharged from the 
abdominal ostium upon the peritoneum, and there is a fresh pelvic peri- 
tonitis. The destructive lesions become greater each time, so that finally 
the extreme changes (pyosalpinx, etc.) already noted may take place. The 
gonococci in the pus of a pyosalpinx may die in the course of several months, 
and a secondary infection with the colon bacillus or the streptococcus or the 
staphylococcus from neighboring or adherent intestines may take place, but 



364 



GYNECOLOGY 





DISEASES OF THE FALLOPIAN TUBES 365 

very often this does not occur and the pus becomes non-infectious. The 
exudate thrown out at the height of the inflammation is absorbed and the 
infiltration of the peritoneum, tubal walls, ovarian capsule, and uterus dis- 
appears to a greater or less extent, but the tube remains permanently dam- 
aged and the ovary adherent or cystic. 

Tubo-ovarian Abscess. — If an ovarian abscess happens to lie in apposi- 
tion with the distended outer extremity of a pyosalpinx, the septum be- 
tween them may break down so that the tubal and ovarian collections of 
pus merge and a tubo-ovarian abscess is formed (Fig. 353). If the outer 
extremity of a pus tube becomes adherent to the ovary at the site of an 
unruptured Graafian follicle, the intervening septum may become thinned 
out and rupture, allowing the pus and the serous contents to merge, secondarily 
infecting the follicle, and leading to the formation of a tubo-ovarian abscess. 



Fig. 354. — Hydrosalpinx (Bryn Mawr Hospital;. 

End-result of Perisalpingitis, — In some cases perisalpingitis may sub- 
side with the formation of only a small amount of exudate, which may be 
entirely absorbed, so that the tube is restored to a normal condition and 
no evidence of the trouble remains. In other instances, where the infec- 
tion has been marked and the exudate massive, the outer surface of the tube 
remains permanently attached to the surrounding structures by adhesions. 
If the adhesions are sufficiently extensive and so placed as to close the 
abdominal ostia of the tubes, the lumen may become distended with clear, 
watery fluid, forming a hydrosalpinx. 

Hydrosalpinx. — A hydrosalpinx is a tube closed at its abdominal ex- 
tremity and distended with clear fluid (Fig. 354). Several factors, as a rule, 
play a part in the etiology ; first, an inflammation of bacterial origin, which 
closes the abdominal ostium by adhesions ; secondly, a closure of the uterine 



36o 



GYNECOLOGY 



end of the tube by distention or kinking, and thirdly, the gradual accumula- 
tion of the normal tubal secretion. Mechanical irritation alone, as, for ex- 
ample, the rubbing of the tubal ostium by a uterine fibroid, or a retro- 
flexed uterus, is not considered sufficient to produce a closure of the tube. 
But such a tumor or displacement of the uterus may predispose to hydro- 
salpinx when the bacterial infection is of slight degree and when it would 
under ordinary conditions subside without notice and without a residuum 
of adhesions. The weight of evidence is that most cases of hydrosalpinx 
follow perisalpingitis of streptococcus, staphylococcus, or colon bacillus 
origin, associated with the post-partal or the post-abortal state. Never- 




FiG. 355- — Tubo-ovarian cyst. (Norris, Gonorrhoea in Women, W. B. Saunders Co.) 

theless, a certain proportion of hydrosalpinx represents a terminal stage of 
pyosalpinx. This statement is based on clinical evidence, such as the 
revelation at operation of hydrosalpinx months or years after well-established 
cases of gonorrhceal pyosalpinx, and upon the histologic features of certain 
cases of hydrosalpinx (hydrosalpinx follicularis) in which the serous fluid 
is confined, not in one large cavity representing the lumen of the tube 
(hydrosalpinx simplex), but in multiple cystic spaces between the stunted, 
partially destroyed, and coalesced folds of mucosa. In such instances an 
antecedent suppurative inflammation of the mucosa is difficult to deny. 

The wall of the tube in simple hydrosalpinx (Fig. 354) is considerably 
stretched and thinned, the degree of distention varying. The hydrosalpinx 



DISEASES OF THE FALLOPIAN TUBES 367 

may be the size of a linger, or it may form a tumor large enough to be pal- 
pated through the abdominal wall, and contain a liter of fluid. In follicular 
hydrosalpinx the total amount of the fluid contained in the numerous cystic 
spaces is comparatively small and enlargement is usually moderate, a hydro- 
salpinx of this sort being rarely thicker than a finger. There are some cases 
of hydrosalpinx which intermittently discharge their contents through the 
uterine end of the tube into the uterus {hydrops tubcc proflncns). 

Tubo-ovarian Cyst. — A tubo-ovarian cyst is a combined cystic disten- 
tion of the tube and ovary. The cyst is filled with clear or blood-tinged 
fluid. A tubo-ovarian cyst may be formed by adhesions between a hydro- 
salpinx and a cystic ovary and the coalescence of their fluid contents by 
rupture or atrophy of the dividing septum. It is likely that some tubo- 
ovarian cysts represent the end stage of a tubo-ovarian abscess — the puru- 
lent material having been absorbed and then replaced by watery fluid (Fig. 
355). A tubo-ovarian cyst forms a retort-shaped tumor. From the outer 
surface it may be difficult to distinguish where the tubal part of the cyst 
ends and the ovarian part begins. Usually, upon opening the tumor, the 
remains of the fimbria, flattened out upon the inner wall at the original 
position of the abdominal ostium, may be distinguished. 

Hematosalpinx, or a distention of the closed tube with blood, may result 
from hemorrhage into a hydrosalpinx which has become twisted on its 
pedicle, or has been subjected to some form of trauma. Usually it is the 
result of an ectopic pregnancy in the affected tube. The consideration of 
haematosalpinx, therefore, naturally falls under accidents to hydrosalpinx or 
tubal gestation. 

NEW FORMATIONS OF THE TUBE 

Polyps. — Polyps are very rare. They are often confused with cir- 
cumscribed thickenings of the mucosa. 

Papillomata. — Papillomata are difficult to distinguish from cancers which 
have a papillary structure, or, on the other hand, from unusually marked 
folding of the tubal mucous membrane. 

Cyst of the Tube. — Cysts of the tube may be miliary, studding the peri- 
toneal surface of the tube and the broad ligament. They may project from 
the abdominal fimbria, and may also occur in the wall of the tube, or under 
the mucous membrane. Tubal cysts may be true hydatids of Morgagni ; 
they may be caused by peritoneal irritation with invagination of the periph- 
eral endothelium, or they may result from lymphangiectasis. 

Myomata. — Myomata have been mistaken for salpingitis nodosa. The 
same is true of adenomyoma. True cases of myoma are rare. These tumors 
vary in size from a hazel nut to an egg. The uterine end of the tube is in the 
usual situation. Microscopically, the tumor consists of fibrous and muscle 
tissue. Adenomyoma is much more frequent and has been discussed. 
(Page 326.) 

. Embryomata of the Tube. — These are usually dermoids. They are very 
rare. Products of an old tubal pregnancy have been mistaken for embryoma. 
The contents resemble those of dermoid cysts elsewhere. Grossly, the tube 
looks like an ordinary sactosalpinx with adhesions. 



368 GYNECOLOGY 

Carcinoma of the Tube. — Carcinoma of the tube is rare. Secondary 
cancer is more frequent than primary. Primary cancer of the tube had been 
reported eighty-six times in 1909. The disease is usually unilateral. Once 
in four or five times it is bilateral. Inflammatory disease of the tube seems 
to predispose to cancer. Carcinoma may begin as a degeneration of a benign 
papilloma, but this is unusual. The tube is, as a rule, enlarged, 
appears like a hydrosalpinx, and is surrounded by adhesions. The tumor 
is rapid in growth, and gives early metastasis. There are no characteristic 
symptoms, the clinical manifestations being usually those of chronic pelvic 
inflammatory trouble. There may be a watery, blood-stained leucorrhoea, 
and at about the cancer age atypical hemorrhage. Pelvic examination usually 
shows a condition simulating pelvic inflammatory trouble. Norris recom- 
mends that, when operating on patients for pelvic inflammatory disease at 
the cancer age, the tubes should be opened before the abdomen is closed and, 
if a papilloma is found, a radical operation should be carried out. 

SYMPTOMS, DIAGNOSIS, AND TREATMENT OF AFFECTIONS OF THE 
FALLOPIAN TUBES 

Acute salpingitis is so uniformly associated with acute pelvic peri- 
tonitis and acute oophoritis that the symptoms, diagnosis, and treatment of 
all three conditions may be logically and conveniently combined under the 
term acute pelvic inflammatory disease (see Chapter XXI, page 411). 

Chronic salpingitis, hydrosalpinx, etc., are likewise so frequently coin- 
cident with chronic oophoritis and pelvic peritonitis that their symptoms, 
diagnosis, and treatment have been considered together under chronic pelvic 
inflammatory disease, page 428. New growths of the tube are acci- 
dental findings or resemble chronic inflammatory disease of the tubes to 
such an extent that they may very properly be included in the latter group, 
at least in so far as symptoms and diagnosis are concerned. In regard to 
treatment, new growths of the tube must be removed by salpingectomy or, 
if the growth is benign, by partial resection of the tube. In the case of car- 
cinoma of the tube, both adnexa and the uterus should be removed. 

ACCIDENTS AFFECTING TUBAL ENLARGEMENTS 

Rupture of Pyosalpinx. — A pyosalpinx rarely may rupture. Bovee, in 19 10, 
was able to find 55 cases recorded in the literature, and Norris found 99 cases 
in 1913. The accident has usually followed trauma of some sort, such as 
coitus, straining at stool, etc. As a result of the rupture and the escape of pus, 
there may be a rapid peritonitis if the pus is infectious. Otherwise the escaped 
pus may be absorbed. The symptoms are acute, agonizing pain in the lower 
abdomen, followed shortly by shock, and later by the evidences of an acute 
peritonitis. If the pus is sterile, the last-mentioned symptoms do not 
appear, although the absorption of the toxic products from the dead bac- 
teria in the tubes may occasion some fever, acceleration of pulse, etc. 

The treatment consists of immediate operation, with the removal of the 
affected tube. Both adnexa and the uterus should be extirpated if they are 
diseased, and if the condition of the patient will permit. 

Rupture of a Hydrosalpinx. — This accident, too, is very infrequent. 



DISEASES OF THE FALLOPIAN TUBES 



369 



The symptoms are sudden, acute pain, followed by shock or the evidence of 
internal hemorrhage. Often it will be impossible to make the exact diag- 
nosis. Operation is advisable, at which time the diseased pelvic organs 
must be removed. 

Torsion of Tubal Enlargements. — Torsion of tubal enlargements occurs 
rarely, there being about eighty-eight cases recorded in the literature in 
1912. In twelve cases a pyosalpinx underwent torsion (Fig. 356). Hydro- 
salpinx is much more likely to undergo this complication on account of 
its retort shape, since the isthmus acts as a pedicle. Other enlarge- 
ments were new growths and ectopic pregnancy. The symptoms 
have most frequently resembled those of acute torsion of an ovarian cyst, 




Fig. 356. — Tuberculous pyosalpinx, torsion and necrosis (University Hospital). 

namely, sudden agonizing pain, shock, rapid pulse, and rapid respirations, 
or of a ruptured ectopic, or acute appendicitis. A positive diagnosis is 
almost impossible, but the condition should be kept in mind. If a twisted tubal 
enlargement is strongly suspected, immediate operation is indicated. The 
twisted tube with its ovary, if that is involved, should be removed. If the 
patient's condition is good, other abnormalities found in the pelvis may be 
dealt with secundum artem. 



EXTRAUTERINE PREGNANCY 

When the fertilized ovum develops outside the uterine cavity the preg- 
nancy is spoken of as extrauterine or ectopic. 

Etiology. — The cause of this condition is some interference with the 
24 



370 GYNECOLOGY 

passage of the fertilized ovum from the ampulla of the tube, where fer- 
tilization usually occurs, into the uterus. Conception need not necessarily 
take place in the tube, for the spermatic particle may advance as far as the 
ovarian fimbriae to meet the ovum or, indeed, penetrate the spot of rupture 
on the Graafian follicle and fertilize an ovum which has remained therein. 
Again, the spermatic particle may wander from the extremity of the tube 
on one side and fertilize an ovum from the opposite ovary, or an ovum of 
one ovary may be fertilized by a spermatic particle in the opposite tube. 
Or, again, an ovum fertilized at the outer extremity of one tube may be 
carried across the pelvis and be swept down the opposite tube into the uterus. 
The factors which may interfere with the passage of the fertilized ovum 
into the uterus are numerous : fibroid tumor in the uterine cornua, congenital 
diverticula in the tube, polyps of the tubal mucosa, obstruction of the lumen 
of the tube by congenital angulation or by an angulation caused by adhe- 
sions, obstruction of the lumen of the tube by inflammatory processes which 



^^^^ 



Fig. 357. — Interstitial pregnancy, (University Hospital). 

form little blind pockets, by reason of the adhesions at the tips of neigh- 
boring plica — all of these may obstruct the passage of a fertilized ovum 
into the uterus. The most common cause, it must be admitted, from both 
clinical and pathological evidence, is some inflammatory lesion of the adnexa. 
Ectopic pregnancy may coexist with normal intrauterine pregnancy. Re- 
peated tubal pregnancy, first in one tube and later in the other, occurs occa- 
sionally. Rarely twin, or even triplet, tubal pregnancy has been observed. 
Varieties of Ectopic Pregnancy.— The fertilized ovum may rest and subse- 
quently develop in a Graafian follicle of the ovary (ovarian pregnancy), upon the 
ovarian fimbriae (tubo-ovarian pregnancy), or within the ampulla (ampullar 
pregnancy), isthmic (isthmial pregnancy), or interstitial (interstitial pregnancy) 
( Fi g- 357) Parts of the tube. Development in some part of the tube is far more 
common than outside of it. It is doubtful whether primary nidation upon the 
peritoneal surface (abdominal pregnancy) occurs— although, secondarily, the 
ovum may become attached in that position after it has escaped from its 
primary resting-place in the tube or the ovary. 



DISEASES OF THE FALLOPIAN TUBES 



371 



Pathology — Nidation of the Ectopic Ovum. — The nidation of the ectopic 
ovum must be somewhat different from the normal intrauterine process because 
the structures with which the ovum comes into immediate relation are not like 
the soft, succulent, decidual endometrium lining the uterine cavity. The 
coverings of the ovum, however, are the same and its outer capsule, the 
chorion, is furnished with the same trophoblast cells and villi — so that it 
has the power of burrowing into tissue and, by osmosis and the corrosion 
and opening up of blood-vessels, of providing itself with nourishment. 
There is some doubt as to the development within the tube of a decidual 
tissue either as a provocative cause of retention of the fertilized ovum, or as 
a result of its retention, or as a common occurrence incident to pregnancy. 
It is likely that there is a slight decidual reaction of the lymphoid stroma 
cells of the plica in most cases of tubal pregnancy. Whether or not this is 
true, the ovum burrows its way either into a fold of the mucosa or between 
adjoining folds. As it goes on growing, the wall of the tube, which has be- 
come somewhat hypertrophied and more 
succulent than during the non-pregnant 
state, is invaded by the ovum which finally 
takes a position within its layers and out- 
side the lumen of the tube. As the ovum 
develops within the wall, the lumen is 
pressed toward the opposite side so that 
on cross-section it may be represented by 
no more than a crescentic slit. The 
chorionic villi take root in the maternal 
tissues by virtue of the corrosive action of 
their syncytial covering. A hemorrhage 
into the tissues surrounding the ovum may 
interrupt its further development. This is 
the fate of a certain proportion of tubal 
pregnancies. Thus a tubal mole is formed, 
which in rare instances may be absorbed. 

the tube remains, sooner or later giving rise to symptoms. It is possible that 
the chorion may keep on groAving for a time after the ovum itself has per- 
ished, otherwise it is hard to understand the number of cases of tubal 
pregnancy giving rise to active symptoms (abortion or rupture) in which 
no trace of the ovum itself can be found. 

Tubal Abortion and Tubal Rupture.— In the majority of cases after the 
tubal gestation has progressed to a certain extent — eight or twelve weeks 
in the most common (ampullar) form — there is a rupture in the surrounding 
muscular and connective-tissue capsule of the developing embryo. This 
rupture may occur either toward the serous coat of the tube if the ovum 
has eaten its way furthest in that direction, or toward the mucous coat if the 
opposite is true. As a result of the former the outer coat of the tube is torn 
and there is free intraperitoneal hemorrhage (Fig. 358) ; the ovum may or 
may not be discharged into the peritoneal cavity. As a result of the latter, 
the ovum escapes into the lumen of the tube, where it excites periodic con- 




FiG. 358. — Early extrauterine pregnancy, rup- 
ture and bleeding, (Bryn Mawr Hospital.) 

In other cases the enlargement of 



372 



GYNECOLOGY 



tractions of the muscular coat which may expel it through the abdominal 
ostium into the peritoneal cavity. In rare instances the weakening and 
corrosion of the tube wall may be toward the mesosalpinx, so that the ovum 
escapes into the broad ligament between its peritoneal layers. 

Fate of the Ovum. — In the majority of cases there is no trace of the 
embryo (Figs. 359 and 360). As the result of hemorrhage into the fcetal 
envelope, as noted above, the ovum has usually perished before abortion or 
rupture occurs. When the ovum is viable at the time of abortion or rup- 
ture, its subsequent fate depends upon whether a placenta has already 
formed and whether it remains attached. Thus the ovum may go on grow- 




Fig. 3.SQ. — Extrauterine pregnancy with beginning tubal abortion. (Bri'n Mawr Hospital.) 

ing outside the tube, being connected by the umbilical cord to the placenta, 
which remains undisturbed therein. Or, if the amniotic sac is unbroken 
(Fig. 361) and the ovum is young, even though the chorion is detached from 
its original nest, the ovum may find a new point of attachment and new 
source of nourishment in the free peritoneal cavity '(abdominal pregnancy). 

Abdominal Pregnancy. — In some cases full development of the ovum has 
taken place in the abdominal cavity. When this occurs, if the foetus is not 
removed by abdominal section at term, it will die. The fat may be con- 
verted into adipocere (lithopedion formation). Such a condition has usu- 



DISEASES OF THE FALLOPIAN TUBES 373 

ally been mistaken for an abdominal tumor of one of the more common 
varieties, and the true state of affairs has been recognized only at operation. 
There will probably be the customary history of tubal pregnancy which 
can be elicited on close questioning, and the patient may recall a consider- 
able amount of pain at the time when labor was due. 

The pregnancy may not go on to term, the growth of the foetus being 
interrupted at some time prior to that period of gestation. Under these 
circumstances the body usually mummifies, or undergoes lithopedion for- 
mation, or the soft parts are absorbed and the skeleton remains. The foetal 
structures may become infected, with the formation of an abscess, which 
subsequently may rupture into the neighboring intestine or bladder, the true 
nature of the process being revealed by the discharge of skeletal parts. 




Fig. 360. — Longitudinal section of tube shown in Fig. 359, blood-clot removed from one side, 
tubal mole in the other side; no gross trace of the ovum. 

Hemorrhage, Pelvic Hematocele, Free Intraperitoneal; Bleeding. — 

Hemorrhage into the peritoneal cavity from external rupture of an ectopic 
ovum is usually great, and the patient may be rapidly exsanguinated. The. 
nearer the point of rupture to the uterine cornu, the larger are the blood- 
vessels which are torn and the more likely is the bleeding to be uninterrupted 
and serious. In tubal abortion the amount of blood lost is less and the 
hemorrhage is slower. When only a small amount of blood escapes into 
the peritoneal cavity, it may become absorbed; when it escapes in larger 
quantity it collects in the dependent parts — Douglas' pouch. Here the fluid 
constituent is absorbed, the blood-clot becomes encapsulated by the organ- 
ization of the peripheral layer and the adhesions which are contracted be- 



374 



GYNECOLOGY 



tween the latter and the surrounding intestines and peritoneum. In the 
course of time the blood may become entirely absorbed, intestinal and peri- 
toneal adhesions being the only evidence of the previous hematocele. Unless 
the hematocele is small, absorption is not the rule. The pelvic mass per- 
sists, gives rise to symptoms — pain, moderate fever, diarrhoea — and, if the 
blood-clot is not evacuated by operation, infection almost always occurs 
with the formation of a pelvic abscess. 

Uterine Changes in Ectopic Pregnancy. — The uterus undergoes some 
hypertrophy in the early weeks of tubal pregnancy. The endometrium is 
transformed into a decidua consisting of the superficial compact and the 
deep spongy layer. The cervix may be very slightly softened, and there 
may be some bluish discoloration of the anterior vaginal wall. Between 

the eighth and twelfth week the compact 
layer of the decidua begins to separate from 
the underlying spongy part and the decidual 
tissue, acting more or less like a foreign 
body, excites contractions of the uterus. 
Hemorrhage also occurs from rupture of the 
small decidual vessels. The decidua may 
be discharged in one piece, exhibiting a per- 
fect mould or cast of the inside of the 
uterus; or as is more commonly the case, 
in small separate portions. After the 
decidua is all discharged the bleeding 
may be continued by subinvolution 
of the uterus, which usually persists 
until the pregnancy has been removed 
by operation. 

Fate of the Pregnant Tube.— The 
enlarged pregnant tube frequently excites 
local inflammatory changes in the structures 
surrounding it, which result in adhesions. 
The pregnant tube may become enveloped 
in omentum ; it may become adherent to the 
peritoneum over the bladder or at the bot- 
tom or sides of the pelvis. 
Symptoms — Previous to Tubal Rupture or Abortion. — The most common 
symptom of ectopic pregnancy before rupture or abortion is an irregular 
but persistent slight bleeding or spotting, occurring with or without a pre- 
ceding cessation of the menses for one or two months. Usually the patient 
has missed a period, but there are many cases in which there has been no 
cessation of menstruation, although something atypical has been noticed 
about the last one. It has been scanty, or long drawn out, or quite profuse 
and then has stopped entirely for a day, only to reappear every day or two, 
a few drops at a time. The patient often believes herself pregnant and 
speculates as to the significance of the returning or atypical menstrual flow. 
Exceptionally, shreds of decidua or even a decidual cast of the uterine 
interior may be recovered by the patient from the bloody discharge. As a 




Fig. 361. — Longitudinal section of pregnant 

tube; ovum in amniotic sac. (Laboratory, 

Gynecean Hospital.) 



DISEASES OF THE FALLOPIAN TUBES 375 

rule, the decidua is expelled in such small disintegrated portions that it 
escapes observation. The associated signs and symptoms of pregnancy are 
not constant or well marked. Morning nausea, fullness, and heat in the 
breasts, and discoloration of the vaginal mucosa may or may not be recog- 
nizable. With the irregular hemorrhage or spotting there is some pain 
which may be more severe on one side, a slight elevation of temperature, 
99 F., and a small increase in the leucocytes, 9000-11,000. These symptoms 
occurring in a woman who has borne children previously, but thereafter has 
remained unproductive for a considerable time, are very significant. All the 
more so if there is a history of some intervening pelvic inflammatory 
trouble at the time of labor or abortion. 

Symptoms of Tubal Rupture or Abortion. — To the above symptoms 
may be added suddenly those which indicate rupture of the tube or a tubal 
abortion. These are acute lancinating pains in one or the other side of 
the lower abdomen, followed by faintness, pallor, rapid respiration, and 
rapid, feeble pulse. If the hemorrhage is free, the severity of the symp- 
toms will be much greater than those resulting from slow or intermittent 
bleeding. Preceding the rupture, there may be a period during which 
the patient suffers at intervals with severe colicky pains in one side of 
the lower abdomen (contractions of the tube, stretching of the peritoneal 
coat) ; rupture of the tube may then be followed by a cessation of the 
greater part of the pain, and the rapid development of the indications of 
internal hemorrhage. The shock attending the pain and the evidences of 
internal hemorrhage may often be progressive up to a certain point and 
then subside, this depending upon whether or not abortion of the ovum 
with cessation of hemorrhage or a rupture of the tube with limited and non- 
recurring hemorrhage has occurred. Sometimes such a history may be 
elicited after the patient has been operated on for another purpose and old 
blood-clots and cicatrices have been found in the tube. 

Symptoms Following Rupture or Abortion in Case of Abdominal Preg- 
nancy. — After the early indications of pregnancy and the symptoms in mod- 
erate degree of rupture or tubal abortion, the subjective manifestations of 
pregnancy may continue and increase even up to term. The abdomen will 
gradually enlarge, foetal movements will be recognized, and the patient may 
consider herself normally pregnant. At term there may be cramp-like pain, 
some hemorrhage, and the discharge of decidual shreds — without expulsion 
of the embryo. At this time, if the condition is recognized, prompt abdom- 
inal section may possibly result in a living foetus. Quite often the true state 
of affairs is not recognized at the time ; the pain and the uterine hemorrhage 
are regarded as false labor, the foetus perishes and undergoes mummification 
or lithopedion formation, and the actual condition is revealed months or 
years afterward. 

Diagnosis — Before Rupture. — The symptoms of an ectopic pregnancy 
vary according to its location, accidents of growth, and termination. No 
other pelvic condition is so frequently mistaken for something else. Never- 
theless, many cases are so typical that a correct diagnosis can be made from 
the history alone. 

Some irregularity in menstruation, particularly amenorrhoea, for six 



376 GYNECOLOGY 

to eight weeks and then " spotting " and abdominal pain in a woman 
a long time married and sterile, or in one who was at first prolific but 
has not been pregnant for some years, often correctly indicate extra- 
uterine pregnancy. If combined with these symptoms the uterus is 
slightly increased in size and a sensitive enlargement on either side to the 
front or back of it can be made out, a diagnosis of unruptured ectopic preg- 
nancy is justified. From threatened or incomplete miscarriage with pelvic 
tumors, inflammatory or otherwise, it often may be distinguished by the 
size of the uterus which does not correspond to the probable duration of 
pregnancy, or by the condition of the os which is not open and is not as soft 
as in intrauterine gestation. The temperature in tubal pregnancy before 
rupture is rarely over 99 ° F. ; there is usually a slight increase in the leuco- 
cytes — 9000-11,000 — rarely more; there is not the dense infiltration and 
fixation of a fresh inflammatory case, and yet the symptoms indicate that 
the condition is something new, something comparatively recent in- the his- 
tory of the patient. Intrauterine pregnancy, with threatened miscarriage 
and a twisted hydrosalpinx or ovarian cyst, may simulate closely. an extra- 
uterine gestation. The indications of a miscarriage, however, are more 
positive, and a true cyst of the ovary is usually larger. 

Diagnosis — At Rupture or Abortion. — The acute pain, shock, and symp- 
toms of hemorrhage at the time of rupture or abortion quite frequently pre- 
vent a satisfactory pelvic examination, and the physician should bear in mind 
that in such an extremity the greatest gentleness must be exercised to prevent an 
exaggeration of the hemorrhage by manipulations of the pelvic organs. 
Under these conditions the diagnosis must be based on the subjective symp- 
toms and history, and upon very gentle examination. It may be evident 
upon inspection that the bluish discoloration of pregnancy is present, that 
the breasts are slightly enlarged, the cervix is softened, and that a very 
sensitive, ill-defined mass exists to one side of, and behind or in front of, the 
uterus, possibly barely felt by the abdominal palpating hand. If the hemor- 
rhage is free, the evidence of fluid blood in the abdomen — dull flanks, fluc- 
tuation, etc. — may be made out. In some cases the pelvic examination is 
absolutely negative and the diagnosis must be based upon the history and 
the subjective indications. The pregnant tube may be enlarged so slightly, 
notwithstanding the fact that a perforation of its wall or the escape of the 
ovum through its outer ostium is causing serious hemorrhage, that even 
intra-abdominal palpation discovers nothing, and actual inspection of the 
tube is necessary to be sure of the source of the trouble. A very consider- 
able amount of free fluid blood in the peritoneal cavity may be unrecog- 
nizable by any method of physical examination. Under such circumstances 
the pallor of the patient is a striking symptom; the conjunctiva and the lips 
are blanched; the skin has a bluish-white or a yellowish hue; the finger- 
nails no longer exhibit the pink capillary flush. When shock without hemor- 
rhage is difficult to distinguish from shock with hemorrhage, a red blood 
count and haemoglobin estimation often afford valuable evidence one way 
or the other. 

Diagnosis of Haematocele Formation.— After the critical symptoms have 
subsided and the blood which has been poured out into the pelvis has formed a 



DISEASES OF THE FALLOPIAN TUBES 377 

clot, a very characteristic, sensation may be imparted to the vaginal or rectal 
finger on bimanual examination ; namely, the peculiar crepitation which may 
be felt upon breaking up a thick jelly. When the clots are older and an 
actual hematocele has formed, the pouch of Douglas may be filled with a 
fairly resistant mass closely incorporated with the uterus and adnexa. Some 
of the blood is usually fluid and may occupy the center of the mass, so that 
the fluctuation may be detected. If infection and suppuration occur, the 
temperature increases and the leucocytosis becomes more marked. When 
the hemorrhage continues slowly and many clots are formed, lying among 
the intestinal coils with beginning organization and plastic peritonitis, there 
may be tenderness and rigidity of the abdominal wall and a considerable 
degree of leucocytosis. 

Diagnosis of Abdominal Pregnancy. — A tubal pregnancy which has rup- 
tured and been extruded into the abdominal cavity and continues to grow may 
give rise to abdominal enlargement, foetal movements, and heart sounds almost 
identical with what is observed during normal intrauterine pregnancy. 
Early in extrauterine pregnancy the enlargement may be a little to one 
side of the median line and later the long axis of the enlargement may be 
transverse or diagonal oftener than in normal pregnancy. The normal out- 
line of the uterus and the uterine contractions, of course, are not apparent, 
but the sensitiveness of the abdomen, and the spasm of the abdominal 
muscles during palpation, may explain this to the physician's satisfaction. 
In doubtful cases, under general narcosis, the discovery by palpation of the 
uterine body, normal or but slightly increased in size, quite distinct and 
separate from the foetal parts, gives sufficient information to establish the 
diagnosis. When the pregnancy has gone on to the third or fourth month 
and the foetus has perished and become mummified or petrified, it forms a 
peculiar enlargement to one side of or behind the uterus, which at once 
impresses the examiner with the fact that he is dealing with something 
unusual. It may be possible to make out the various foetal parts. The 
greatest difficulty in doing this may arise if a recent intrauterine pregnancy 
complicates an old extrauterine pregnancy. 

Prognosis. — The prognosis of extrauterine pregnancy is always doubt- 
ful. At the present time, in good hands, few cases will progress beyond the 
first two or three months of gestation without being recognized, and as soon 
as the diagnosis is certain will be exposed to operation. The mortality rate 
in operation en ectopic gestation is no higher than in any uncomplicated 
aseptic celiotomy. Neglected cases, whether early or late, may end dis- 
astrously. Cases seen for the first time when rupture or tubal abortion has 
occurred or is imminent, if dealt with promptly and properly, will usually 
recover. Cases which are exposed to operation some time after free intra- 
peritoneal hemorrhage has occurred with the subsequent formation of clots, 
show a mortality a bit higher than the usual celiotomy cases because of the 
greater tendency to post-operative infection, bacteria already being pres- 
ent in the hematocele or the clots left after the enucleation and forming an 
unusually favorable nidus for the growth of germs introduced by accident. 
The prognosis of cases not submitted to operation early or late is unfavor- 
able. Suppuration of the hematocele and spontaneous evacuation into the 



378 GYNECOLOGY 

bowel or bladder have been observed. The hemorrhage may continue and 
the amount of blood in the peritoneal cavity gradually increase with the 
extensive distribution of clot, plastic or septic peritonitis, and death. 

Treatment. — There is but one form of treatment for tubal pregnancy and 
that is operation. The only questions to be decided are when to operate 
and what the nature of the operation shall be. As a rule, it may be said that 
operation should be undertaken as soon after the diagnosis is made as the 
patient can be properly prepared. This applies to unruptured as well as 
ruptured and tubal abortion cases. The only exception to this rule is in 
advanced cases of abdominal pregnancy, in which operation is deferred, hop- 
ing that a viable child may be secured by celiotomy at term. In the early 
stage of extrauterine pregnancy the patient should be immediately placed 
under such conditions that she can be exposed to operation at short notice. 
After the usual preliminary examination and preparation, which is advis- 
able in all but emergency cases, operation should be carried out. At this 
time the pregnant tube should be removed by salpingectomy, and other 
pelvic lesions found at the time treated secundum art em. 

Operation at the time of rupture or abortion, when the patient's condi- 
tion is critical, must be consummated with the least possible delay. Every- 
thing should be prepared, the operator and his assistants, the instruments, 
the sutures, the abdominal surface, and the patient on the operating table, 
before anaesthesia is begun. In this way not a moment is lost. Nitrous oxide- 
oxygen and ether anaesthesia is the best for this operation. Apparatus for the 
subcutaneous injection or the intravenous infusion of salt solution must be at 
hand. In the most desperate cases the intravenous cannula should be in posi- 
tion and everything ready to start the injection as soon as pelvic haemostasis 
is secured. As soon as the abdomen is opened the site of the pregnancy 
should be determined by palpation and a clamp placed on the broad liga- 
ment, close to the uterus on the affected side, to secure the utero-ovarian 
anastomosis, and another close to the pelvic extremity of the broad liga- 
ment to secure the ovarian vessels. This may be done by touch alone, if 
necessary, and no attention should be paid to the fluid blood or clots which 
may gush from the incision as soon as it is made. After the bleeding area 
has been caught between clamps in this way and hemorrhage can no longer 
occur, the excess of bloody fluid and clots may be removed by sponging, 
and the pelvis sufficiently exposed and isolated to carry out salpingectomy 
or salpingo-oophorectomy, whichever is required. In desperate cases the 
simplest technic should be used, the chief aim of the operator being to get 
the abdomen closed quickly after ligating the vessels and removing the 
bleeding tumor. The gross fluid and clotted blood should be scooped out and 
the incision closed without delay. If the hemorrhage is recent, and the pa- 
tient's condition serious, the abdominal cavity should be filled with salt 
solution before closing the peritoneum. If there is much old blood in the 
pelvis, and the operation has taken place during a recurrence of the hemor- 
rhage, drainage through Douglas' pouch or a suprapubic opening should 
be employed. 

The advice here given is not in accord with the teachings of a few gyne- 
cologists who in desperate cases advocate delay until reaction occurs. The 



DISEASES OF THE FALLOPIAN TUBES 379 

assumption underlying this position is that the hemorrhage will cease 
when the blood-pressure has been reduced to a certain point, provided the 
patient is not disturbed by pelvic examination, transportation to a hospital, 
and stimulation. The application of this teaching has not been successful 
in practice and is generally considered pernicious. But the discussion of 
the question has emphasized several very important points : First, that a 
pelvic examination in ruptured tubal pregnancy or tubal abortion may seri- 
ously increase the amount of hemorrhage ; that nothing but the gentlest 
examination is permissible, and that it should not be repeated. Secondly, 
that the active use of cardiac stimulants, hypodermoclysis, etc., may 
prolong the hemorrhage, prevent the formation of clots, and actually exsan- 
guinate the patient. The practical deductions from these facts are : To 
rely upon the history or to make but one examination, and that in the 
gentlest manner ; to use morphine hypodermically to quiet the patient after 
a positive diagnosis is made ; to transport the patient with the greatest care 
compatible with speed to the nearest operating room ; to avoid any but the 
mildest and most carefully guarded stimulation until the bleeding vessels 
are controlled by ligature. 

When the case is of long standing, the hematocele well organized, and the 
patient in such a state that there need be no undue haste, careful attention 
should be paid to technic ; the ovary on the affected side may be conserved, 
the opposite adnexa examined and dealt with in approved fashion. When the 
hematocele has been everywhere adherent, so that small pieces of blood-clot 
must be left attached to peritoneal surfaces in the pelvis, or in any case in 
which the possibility of infection seems more pronounced than usual, drain- 
age through a posterior vaginal or suprapubic incision should be instituted. 

In the case of suppurating pelvic hematocele, the most suitable method of 
treatment consists in a posterior vaginal incision, evacuation of the pus, 
and drainage. 

In advanced abdominal pregnancy the sac may be surrounded by dense 
adhesions or it may be free, hence its removal may be either very difficult or 
quite as easy as the removal of an ordinary cyst. The chief difficulty, however, 
is in dealing with the placenta. The hemorrhage caused by removing this 
at once may be rapidly fatal. At term or near term it should never be 
attempted ; instead, the margins of the foetal sac should be stitched to the 
abdominal incision, the umbilical cord cut short, the cavity packed with 
gauze, and the placenta permitted to separate slowly. When the foetus in 
abdominal pregnancy dies near term, operation should be deferred for 
three or four weeks, to allow the vessels at the placental site to become at 
least partially obliterated. 

BIBLIOGRAPHY 

Anspach, B. M. : "Torsion of Tubal Enlargements with Special Reference to Pyosalpinx." 
Amer. Jour. Obst., 1912, lxvi, 553 ; Ibid. : " Four Cases of Extrauterine Pregnancy with 
Reference Especially to Their Etiology." U. of P. Bull., July, 1902. 

Eovee, J. W. : " Acute Diffuse Suppurative Peritonitis from a Ruptured Pus Tube." Surg., 
Gyn. and Obst., 1910, x, 406-411. 

Clark, J. G., and Norms, C. C. : " Conservative Surgery of the Pelvic Organs in Cases of 
Pelvic Peritonitis and of Uterine Myomata." S., G. and O., 1910, xi, 398; Ibid.: 
" Results Following the Treatment of Pelvic Inflammatory Lesions by Surgical Meas- 
ures." S.. G. and O., 1917, xxv, 33. 



380 GYNECOLOGY 

Cragin, E. B. : " The Treatment of Full Term Ectopic Gestation." Am. J. Obst., igoo, 

xli, 740. 
Dorland, W. A. N. : " Repeated Extrauterine Pregnancy." Am. Jour. Obst., 1898,. 

xxxvii, 478. 
Frank, R. T. : " An Analysis of Eighty Consecutive Cases of Ectopic Gestation." Amer. 

J. Obst., 1909, lix, 211. 
Fromme u. Heyneman : "Die Hydrosalpinx." Veits Handbuch, 2nd Edt, p. 137. 
Futh : " Studien iiber die Einbettung des Eies in der Tube." Monats. f. Geb. u. Gyn., 

1898, 590-613. 
Gellhorn, G. : " Salpingostomy and Pregnancy." Trans. Amer. Gyn. Soc, 191 1, xxxvi, 186. 
Glitsch : " Zur Aetiologie der Tubenschwangerschaft." Arch. f. Gynak., 1900, lx, 385. 
Hofmeier : " Zur Pathologie der Extrauterinschwangerschaft." Berlin, Klin. Woch., 1905, 

xxvii, 847. 
Kleinhans : " Die Erkrankungen der Tube." Veits Handbuch, iii, 1st Edition. 
Landau u. Rheinstein : " Beitrage zur Pathologische Anatomie der Tube." Archiv f . G. r 

1891, xxxix, 273. 
Mandl u. Schmidt: "Beitrage zur Aetiologie und Pathologischen Anatomie der Eileiter- 

schwangerschaften." Arch. f. Gyn., 1898, S. 401. 
Martin : " Ueber Partielle Ovarien und Tubal Extirpationen." Volk. Samm. Klin. Vrot, 

1889; Ibid. : Die Krankheiten der Eileiter. Leipzig, 1895, Bd. 1. 
Martin u. Orthman: Eileiterschwangerschaft. Die Krankheiten der Eileiter. Berlin 

und Leipzig, 1895. 
Norris, C. C. : "Primary Carcinoma of the Fallopian Tube and the Report of a Case." 

S., G, and O., 1909, viii, 272. 
Opitz : " Ueber die Ursachen der x\nsiedelung des Eies im Eileter." Zeit. f . Geburtsch. u. 

Gynak., 1902, Bd. xlviii. 
Parry : Extrauterine Pregnancy. 1876. 
Pozzi : De la re'section et de L'ignipuncture de gyn. 1897. 
Robb, H. : " Ectopic Gestation with Special Reference to the Treatment of Tubal Rupture." 

Amer. Jour. Obst., 1907, lvi, 6. 
Robson : " Primary Ovarian Gestation." Trans. London Obst. Soc, 1902, xliv, 215. 
Rubin, I. C. : " The Simulation of Corpus Luteum and Retention Cysts of the Ovary with 

Ectopic Pregnancy and Early Uterine Abortion." Surg., Gyn. and Obst., 191 7, xxiv, 443. 
Runge: " Beitrag zur Anatomie der Tubargraviditat." Arch. f. Gyn., 1904, lxxi, 652. 
Sampson, J. A. : " Influence of Ectopic Pregnancy on the Uterus." Trans. Amer. Gyn. Soc, 

1913, xxxviii, 121. 
Simpson, F. F. : " Deferred Operation for Ruptured Ectopic Gestation." Surg., Gyn. and 

Obst., 1907, v, 503; Ibid. : "Deferred Operation for Intra-abdominal Hemorrhage Due 

to Tubal Pregnancy." Trans. Amer. Gyn. Soc, 1908, xxxiii, 19. 
Skutsch : " Beitrag zur Operativen Therapie der Tubenerkrankungen." Centr. f . Gyn., 

1889. 
Smith, R. R. : "Repeated Ectopic Pregnancy." Trans. Amer. Gyn. Soc, 1911, xxxvi, 425; 

Ibid.: "Final Results (after five years) in 192 Patients Operated Upon for Ectopic 

Pregnancy ; with Special Reference to Subsequent Uterine and Repeated Ectopic Preg- 
nancies." Surg., Gyn. and Obst., 1914, pp. 684-695. 
Spalding: "Relative Frequency of Ectopic Gestation." Trans. Sec. O. G. and A. S. — 

A. M. A., 1915, p. 114. 
Tait, L. : Lectures on Ectopic Gestation and Pelvic Hematocele. Birmingham, 1888. 
Veit, J. : Die Verschleppung der Chorionzotten. Wiesbaden, 1905. 

Webster, J. C. : Ectopic Pregnancy. 1895 ; Ibid. : " Study of a Specimen of Ovarian Preg- 
nancy." Am. Jour. Obst., 1904. 
Werth : " Die Extrauterinschwangerschaft." Winckels Handbuch der Geburtshiilfe iqoj 

Bd. ii, 2, 655- 
Williams, J. W. : " Extrauterine Pregnancy." Kelly-Noble Gyn. and A. Surg., ii, 30. 

(Complete literature.) 



CHAPTER XX 
DISEASES OF THE OVARIES 

INFLAMMATORY DISEASES 

Acute Interstitial Oophoritis — Etiology. — Acute interstitial oophoritis 
may be caused by the direct extension, via the lymphatics, of an infection 
deposited in the uterus, incident to abortion, labor, or instrumentation (strep- 
tococcus, staphylococcus, colon bacillus, etc.). Acute interstitial oophoritis 
may also occur secondary to acute endosalpingitis, an open Graafian follicle 
or corpus luteum being infected by purulent material escaping from the 
tube (gonococcus). 

It is a matter of clinical observation that acute interstitial oophoritis may 
complicate parotitis, scarlet fever, varioloid, measles, diphtheria, and typhoid 
fever (Frankl). The work of Rosenow and Davis shows that interstitial 
oophoritis may be hsemogenic, the organisms being transported to the ovary 
from the site of focal infections, notably the tonsils or the teeth. In a series 
of fibrocystic ovaries exhibiting fibrocystic changes, Davis found the strep- 
tococcus viridans in 50 per cent. Other bacteria isolated were the staphylo- 
coccus albus, the pneumococcus, and an organism resembling the diphtheria 
bacillus. Davis regards this study as conclusive proof of the occurrence of 
hematogenous involvement of the ovaries from some of the more common 
foci of chronic infection. 

Pathology. — Acute interstitial oophoritis complicating post-abortal, post- 
partal, or instrumental infection is marked by cedema and swelling of the 
ovary and infiltration of the ovarian stroma with polymorphonuclear leuco- 
cytes. In the milder grades of infection the disease may subside without 
producing gross lesions. In the severer forms there is destruction of tissue 
with the formation of an abscess. An ovarian abscess of this type varies in 
size from that of a hazelnut to that of an orange (Fig. 362). There may be 
a number of small purulent collections at first, but these usually merge into 
one as the disease advances. When the acute interstitial oophoritis is the 
consequence of a direct infection of an open Graafian follicle or corpus luteum 
by gonorrhceal pus from the tube, the inflammatory process is more or less 
limited to the infected follicle or corpus luteum. Abscess is not so frequent, 
and if it ocurs is usually smaller and confined to the follicle or the corpus 
luteum, as the case may be. 

Acute Perioophoritis — Etiology and Pathology. — Acute perioophoritis 
or acute inflammation of the ovarian capsule is most frequent in association 
with gonorrhceal salpingitis and pelvic peritonitis. The ovarian capsule be- 
comes inflamed and very quickly covered with or embedded in the inflamma- 
tory products of the pelvic peritonitis. As a rule, in these cases the ovarian 
involvement is limited to the capsule, but, as noted above, exceptionally an 
interstitial oophoritis may be produced. Perioophoritis also may accom- 
pany and be a part of interstitial oophoritis or pelvic peritonitis caused by a 

381 



382 



GYNECOLOGY 



post-abortal, post-partal, or post-instrumental infection. The changes in the 
capsule in this instance are not so marked, and the condition is usually sec- 
ondary in importance and significance to the lesions which it complicates. 
End-result cf Acute Interstitial Oophoritis. — Following an acute inter- 
stitial oophoritis the inflammation may subside without any recognizable 
gross or histologic lesion, or the ovary may be permanently damaged and 
exhibit sclerosis, hypertrophy, or cystic degeneration. An abscess of the 
ovary, the size of an orange, causes active symptoms and must usually be 
evacuated by surgical interference, or, if the case is neglected, it may rup- 
ture spontaneously into the vagina, the intestine, or the bladder. The ovary 
may then return to an approximately normal size and appearance, or, if the 
greater part of the organ has been destroyed, it may be shrivelled and 
sclerotic. In the case of small abscesses, especially those secondary to 
gonorrhceal salpingitis and peritonitis, the acute process may subside and the 

purulent content be gradually 
disintegrated and partially 
absorbed. 

End-result of Acute Peri- 
oophoritis. — A cute peri- 
oophoritis of gonorrhoeal origin, 
associated with gonorrhceal 
salpingitis and pelvic peri- 
tonitis, leaves the ovary with a 
thickened capsule and adhe- 
sions to the surrounding struc- 
tures. In the course of time 
the ovary becomes cystic from 
the interference with the peri- 
odic rupture of ripe Graafian 
follicles (see Retention Cysts. 
page 402) . Acute peri- 
oophoritis, associated with 
interstitial oophoritis without abscess formation, may leave no permanent 
residue, the adhesions formed during the acute stage often entirely disappear- 
ing as the trouble subsides. Perioophoritis associated with ovarian abscess 
is more likely to be followed by permanent adhesions ; this is especially true 
when the abscess is of small size and has not been evacuated. 

Symptoms, Diagnosis, and Treatment of Acute Inflammatory Diseases 
of the Ovaries. — Acute oophoritis, both the interstitial and perioophoritic 
varieties, are almost invariably combined with cellulitis, peritonitis, or 
salpingitis. The symptoms, diagnosis, and treatment of all these conditions 
are so intimately combined that they are considered together under pelvic 
inflammatory diseases. Oophoritis is a more common incident of post-partal, 
post-abortal or instrumental pelvic inflammatory disease than of gonorrhoeal 
pelvic inflammatory disease. The subject is dealt with in Chapter XXI, page 411. 
Chronic Oophoritis. — Chronic oophoritis, either interstitial or peri- 
oophoritic, is the end-result of an originally acute lesion (vide supra). It 




362. 



Abscess of the ovarv (Gynecological laboratory 
U. of P.). 



DISEASES OF THE OVARIES 383 

is usually associated with chronic salpingitis or chronic pelvic peritonitis, 
and is a part, therefore, of chronic pelvic inflammatory disease. The symp- 
toms, diagnosis, and treatment are described in Chapter XXI, page 411. 

TUMORS OF THE OVARY 

The ovary may be the seat of a variety of tumors. Tumors of an 
epithelial type originate in the epithelium of the Graafian follicle or the 
germinal epithelium, or in rests of the Wolffian system embedded 
in the ovary, while connective-tissue growths develop from the ovarian 
stroma. The epithelial tumors are almost uniformly cystic and far out- 
number the solid tumors. Both solid and cystic growths may be 
either benign or malignant. Another form of ovarian tumor, etiologically 
and structurally different from either of the above, is the teratoma. These 
are usually cystic and take the form of the so-called dermoid cyst. Rarely 
they are solid or nearly so. In addition to these actual new growths of the 
ovary, there are other enlargments of the organ due to hyperplasia and hyper- 
trophy of its constituents, and not in any sense true tumor formations. 
They result from abnormalities in the growth, development, and regression 
of the Graafian follicle and the corpus luteum. 1 

1 For convenience the tumors of the ovary may be grouped as follows : 
Tumors of the Ovary. 

{ Glandular cysts ] Pseudomucinous 
i -d ■ ( Ovary proper <! (adeno-cystomata) \ 

"(eiSpt some \ I of the OVary J SerOUS 1 Papilloma- 

Epithelial papillomata) p ■ / Cysts of the 1 j tous Cysts. 

new growths ' \ Parovarium / " " ' 

[ Carcinoma 
_ Malignant \ Primary-Secondary 

( Carcinomatous degeneration of ovarian or parovarian cysts. 

Connective tissue f Benign — Fibroma — Fibromyomata 

new growths \ Malignant — Sarcoma — Endothelioma — Perithelioma 

{ Malignant 
C "Dermoids" . . . \ degeneration 

rp , /Cystic or J " Struma ovarii " [occasionally. 

Ieratoma \ solid (rare) " Hydatidiform- 
[ mole- like" 

Combined carcinoma } , Kruckenb tumor . 
and sarcoma. / 6 

Graafian follirle rvsfq / Cystic degeneration of the ovary. 
Uraanan toiiicle cysts <J Hydrops fomc uH. 

v Corpus luteum cysts { expound theca-lutein cysts. 
In this classification of ovarian tumors, there do not appear some of the varieties 
noted elsewhere, such as unilocular, multilocular, intraperitoneal, intraligamentous, extra- 
peritoneal, etc. However, it will be at once observed that these adjectives refer to the 
minor physical characteristics and to position. Thus, a unilocular cystic tumor may origi- 
nally have been a glandular cystomata of the ovary in which all the septa have broker! down 
so that all the cystic cavities have become merged into one, or it may be a parovarian tumor. 
A multilocular cyst may belong to the glandular cystomata, or it may be a dermoid. An 
extraperitoneal or an intraligamentous tumor is usually a cyst of the parovarium, but it may 
be a teratoma. These descriptive terms are, therefore, not pertinent to the classification 
of ovarian tumors in family groups or upon an etiological basis. 



Combined epithelial 
and connective tis- 
sue new growths 



Retention cysts of 
the ovary 



384 GYNECOLOGY 

EPITHELIAL NEW GROWTHS 

The benign epithelial new growths of the ovary commonly exhibit 
a massive proliferation of glands with retention of the excretory prod- 
ucts and the formation of cystic spaces. These are the glandular 
cysts, adenocystomata of the ovary. Secondarily, malignant degen- 
eration may take place in them, and is most likely to affect certain types, 
as will be noted later. The malignant epithelial new growths of the ovary 
commonly exhibit the structural characteristics of an adenocarcinoma. The 
glandular formation is considerably in evidence, so that the tumor is semi- 
solid or cystic. Infrequently the tumor is nearly solid. 

Glandular Cysts — Etiology. — Adenocystomata are the commonest new 
growths of the ovary. In what structures they originate is a matter of 
speculation. 2 Three theories deserve especial consideration. The first is 
that they spring from the granulosa cells of the Graafian follicle ; the second 
is that down-growths of the germinal epithelium from the surface of the 
voung ovary become snared off in the stroma of the ovary and later in life 
develop into glandular cystomata. The third, and the one which 
seems most likely, is that glandular cysts of the ovary arise from embryo- 
logic remains of the Wolffian tubules, the pseudomucinous tumors from the 
secreting and the serous tumors from the collecting tubules. The latter 
theory is the one suggested by Clark 3 and is based on MacCallum's 
notes on the Wolffian system. 

Pathology. — An adenocystoma arises within the substance of the ovary 
and in the course of its growth destroys the ovary. The growth is usually 
intraperitoneal and is not covered by peritoneum, so that the surface of the 
tumor is dull white in color, corresponding to the appearance of the tunica 
albuginea. Exceptionally the growth may be partly intraligamentous, and 
in that event the corresponding area of the tumor will be covered with 
peritoneum. Glandular cystomata almost always reach the size of the 
foetal head before they attract attention ; exceptionally they may be 

2 In accounting for the origin of ovarian cystomata, the pseudomucinous" tumors, 
because of the dissimilarity between their epithelium and that normally found on 
the surface or in the follicles of the ovary, have been ascribed to a particular origin. 
Possibly the most plausible theory is that pseudomucinous cystadenomata are in reality 
teratomata in which the characteristic glandular structures overwhelmingly prevail (Hanan, 
Pfannenstiel, Pick, Frankl). It is believed that the serous cystadenoma arise from the 
germinal epithelium and from isolated downgrowths of the same, or from the follicle 
epithelium (Doran, Waldeyer, Williams, Walthard.). 

3 Clark discusses the four theories relative to the etiology of glandular cysts of the 
ovary. These tumors have been thought to arise : First, from Pfliiger's tubules. Secondly, 
from Graafian follicles. Thirdly, from detached portions of Miillerian ducts. Fourthly, 
from remains of Wolffian body. Clark does not believe in the first theory, but adheres to 
Waldeyer's theory that the germinal hillock is first divided into ova compartments by out- 
growths of connective tissue, shooting upward from the underlying Wolffian body into the 
mass of epithelium, and that these compartments are ultimately subdivided into the primi- 
tive follicles. He does not believe in Pfliiger's tubules as the point of origin of glandular 
cysts, nor does he believe that the cells of the Graafian follicles can undergo such a 
metaplasia as would be necessary to cause them to change not only their morphology, but 
also their physiology. He does not believe in the development of the glandular cysts from 
the detached portions of the Miillerian ducts. 

Clark then describes a case, a woman aged fifty-five, in which at operation he found a 
multilocular ovarian cyst; in the opposite ovary he found at the hilus a number of small 
cysts which, after serial study, he concluded from their location, etc., could only represent 



DISEASES OF THE OVARIES 



385 



found when appreciable enlargement of the ovary is just beginning. 
Usually, however, they present themselves as tumors of large dimensions 
filling the pelvis and the lower abdominal cavity. They sometimes grow to 
enormous proportions, tumors weighing eighty pounds having been re- 
ported. They grow with comparative rapidity even when not malignant, 
and are limited only by the size of the individual and the nourishment she 
can furnish. In mammoth tumors the weight of the host may be consid- 
erably less than the weight of the tumor. As the tumor increases in 







Fig. 363. — Sagittal section showing displacement of small uterus 
by large multilocular cyst. 

size, the patient usually slowly emaciates, the parasitic growth taking from 
her strength and sustenance. As the ovary enlarges, it exerts traction upon 
the posterior surface of the broad ligament and forms a pedicle consisting of 
the upper part of the broad ligament, the mesosalpinx, the tube, and some- 

a beginning cystic dilatation of the remains of the Wolffian body. He makes the fol- 
lowing resume : 

First, in the broad ligaments of the adult woman the Woman duct and its collecting 
tubules are represented by the so-called Gartner's duct and the parovarian tubules. 

Secondly, if MacCallum's excellently reconstructed tubular system of the Wolffian duct 
is correct, the secretory portions of the tubules must be accounted for in the adult ovary. 

Thirdly, the origin of multilocular glandular ovarian cysts is much more rationally 
explained upon the basis that they spring from these embryonic remains of the secretory 
system than from pathologic changes occurring in the Graafian follicle, or in the remains 
of the so-called Pfliiger's tubules. 

Fourthly, the case above described shows a glandular secretory tubular system which 
strongly suggests in its devious ramifications that described by MacCallum as the secretory 
portion of the Wolffian tubules. 

Fifthly, at various points in this tubular system dilatations forming loculi are noted, 
suggesting the theory that multilocular glandular ovarian cysts arise from outgrowths of 
these embryologic remains of the secretory portions of the tubular system of the 
Wolffian body. 
25 



386 



GYNECOLOGY 



times a part of the round ligament. The tube is not otherwise affected, 
but retains its normal size and relation to the ovary. Glandular 
cystomata at first lie within the true pelvis, but later unless adherent, as 
they increase in size, they rise above the pelvic brim and distend the abdo- 
men. During the time they occupy a pelvic position they displace the 
uterus to one side and to the front of the pelvis ; when they are large enough 
to distend the abdomen they may pull the uterus above the pelvic brim. In 




Fig. 364. — Multilocular cystadenoma of the ovary. (Gynecological Laboratory, U. of P.) 

the largest tumors the pelvis is usually filled by one pole or lobulation of 
the cyst. The tumors are usually globular or spherical in shape, sometimes 
elliptical. The surface is somewhat irregular, the growth presenting a tabu- 
lated appearance ; the smaller lobes give some irregularity to the surface and 
represent the denser part of the tumor ; the larger lobes have a smoother 
contour corresponding to the larger cystic areas. On section the tumor is 
seen to be made up of cystic spaces of varying size. Usually there is one 
large cavity, the " mother cyst," and a number of smaller cavities, the 



DISEASES OF THE OVARIES 



387 



* daughter cysts ; " the mother cyst formed by the rupture of the septa and 
the coalescence of neighboring daughter cysts. The relative proportion of 



/ 
/ 



\ 



MO-ft^ 




^ 



r 



Fig. 365. — Diagram showing the difference in effect upon the cervix when a solid 
tumor of the uterus and a cystic tumor of the ovary is lifted or pushed up. 

the growth made up of the larger and smaller cystic spaces varies consider- 
ably. It may be that none of the cystic cavities are of large size, so that the 
growth externally has more of the characteristics of a semi-solid than of a 



388 GYNECOLOGY 

cystic tumor. Exceptionally all the cysts may have coalesced into one, so 
that the cyst is composed of a single loculus in the walls of which the rem- 
nants of the broken-down septa between the original smaller cysts may 
be discerned. 

The contents of the cysts vary according to the type of epithelium lining 
the cystic spaces and glands, and according to the accidents which have 
occurred in the life of the tumor. The glandular epithelium in a 
majority of glandular cystomata is of the high columnar goblet type and 
secretes a thick, glairy, semi-opaque, tenacious fluid, spoken of as pseudo- 
mucin. 4 This variety of the adenocystomata is known as pseudomucinous. 
In other adenocystomata the epithelium is of the low columnar or cuboidal 
type, and the cyst contents are thin and watery ; these tumors are spoken of 
as serous adenocystoma. Cellular debris from disintegrated septa may be 
found in the cyst content, and the fluid may be chocolate colored from 
admixture with blood. 

Pseudomucinous cysts are supposed to develop from rests of the glom- 
eruli of the Wolffian system, whereas serous cysts are derived from the 
excretory tubules. As a matter of fact, many tumors contain both varieties 
of cells and contents, although one or the other variety usually predomi- 
nates. The true pseudomucinous cysts are invariably multilocular, whereas 
the pure serous cysts occasionally may be unilocular. 

Serous cystomata are more inclined to papillomatous formation {vide infra). 

Papillomatous cysts most frequently become malignant. 

Glandular cysts of the ovary, unless complicated by inflammation or 
malignancy, do not form adhesions. 

Symptoms. — Glandular cysts of the ovary may present few or no sub- 
jective symptoms until they are sufficiently large to distend the abdomen. 
There may be some abnormality of the menstrual periods from destruction 
of the follicles and interference with the formation of the corpora lutea. But 
these symptoms are by no means constant and are frequently disregarded 
by the patient. Very often the first intimation the patient has that anything 
is wrong comes from the realization that the abdomen is gradually increas- 
ing in size. Not infrequently the patient relates that she first noticed that 
her clothes seemed tight and this drew her attention to her increase in girth. 
As the abdominal distention becomes greater, there is a certain amount of 
abdominal uneasiness and distress due to displacement of the intestines, and 
there may also be considerable respiratory embarrassment from pressure 
upon the diaphragm. If the tumor reaches colossal proportions the patient 
emaciates and in time presents a weazened facies. In the most extreme 
cases the tumor may weigh as much as, or more than, the patient ; there is 
then marked cardiac and respiratory embarrassment, general weakness, diffi- 
culty in locomotion, and oedema and varicosities of the lower limbs and 
abdominal wall. Glandular cysts of the ovary which are complicated may 

4 Pseudomucin. The semifluid content of some ovarian cysts is called pseudomucin or 
albumin. It is similar in some ways to mucin, but it is easily split by boiling with acid so 
as to produce a carbohydrate, a glycoproteid, which will reduce copper (Fehling). Pseudo- 
mucin is not coagulated by boiling or by the addition of mineral acid, as is mucin, nor is 
it precipitated by acetic acid as is mucin. Pseudomucin is precipitated by alcohol ; albumin 
is not. 



DISEASES OF THE OVARIES 389 

give rise to symptoms of a very different character from those described 
(see Complications of Ovarian Tumors, page 405). 

Diagnosis. — A glandular cyst of the ovary, which has not reached suffi- 
cient proportions to cause abdominal enlargement and is uncomplicated, is 
felt as a globular, freely movable tumor to one side of or behind the uterus. 
The uterus is displaced anteriorly and to the opposite side. The tumor and 
the uterus can be separated bimanually. The tumor is elastic or semi- 
fluctuant, and may be pushed upward without elevating the uterus (Fig. 365) 
(see Differential Diagnosis of Myomata, page 308) ; the ovary cannot be felt as a 
separate body on the affected side. An ovarian cyst of this size, when adherent, 
may closely simulate a subperitoneal myoma, especially if the capsule is thick 
and the cyst is tensely filled. Fluctuation in the ovarian tumor may then be 
indistinguishable and differentiation from a myoma nearly or quite impos- 
sible. The diagnosis will be simplified when other fibroid nodules can be 
felt attached to the uterine body. In such cases an effort should be made to 
distinguish the ovary on the affected side, and to determine, as accurately 
as possible, the length of the endometrial cavity ; whereas the uterus, which 
is the seat of a myoma, is almost invariably elongated ; its length is usu- 
ally unaffected by an ovarian cyst. It may be necessary, in order to deter- 
mine this point precisely, to pass a sound into the uterus ; if surgical relief 
has been elected in a given case, such means of exact diagnosis may be left 
until the time of the operation. 

The differentiation between uterine myoma and ovarian cysts causing 
abdominal enlargement is usually easy. The myomatous uterus is less 
likely to occupy a median position ; there is almost always a certain amount 
of asymmetry and difference between the two sides ; the surface of the 
growth is much more irregular, the consistency decidedly greater, and there 
is no fluctuation. If one or more hard, pedunculated nodules can be dis- 
tinguished on the surface of the growth, it is almost prima facie evidence of 
myoma. The abdominal wall over the tumor rises to its summit abruptly, 
giving the abdominal parietes the appearance of being bodily pushed for- 
ward by an underlying, unyielding, irregular body. The ovarian tumor is in 
the median line, unless adherent ; it is usually of larger dimensions than the 
fibroid ; the abdominal wall above the tumor rises gradually to its summit ; 
enlargement of the abdomen is usually quite symmetrical ; the tumor is 
semi-elastic to the touch, presents signs of fluctuation, and is less apt to 
show surface irregularities. Over both uterine myomata and ovarian cysts 
dulness may be elicited by percussion, and surrounding the enlargement, 
except at its pelvic attachment ; that is, above the symphysis, there is an 
area of resonance spoken of as coronal resonance. 

In differentiating between ovarian cysts and pregnancy, an attempt should 
be made to outline the body of the uterus as distinct from the tumor ; in 
cysts of small or moderate size, this may be readily accomplished; in tumors 
of larger dimensions it may be difficult or impossible. Under such circum- 
stances lack of the symptoms and signs of pregnancy may be sufficient to 
exclude that condition. Pregnancy after the fifth month can be recognized 
by the foetal movements and the foetal heart sounds, and it is at this period 
that the signs are most valuable, for ovarian tumors corresponding in size 



390 GYNECOLOGY 

to the earlier months of pregnancy can be more readily separated from the 
uterus on bimanual palpation than the larger growths. 

From tympanites and an accumulation of fat, ovarian cysts may usually be 
distinguished by the fact that there is no definite or distinctly outlined tumor 
mass, that the percussion over the most prominent part of the abdomen is 
resonant or tympanitic, that cathartics and enemas diminish the enlargement 
in the case of tympanites, and that there is no true fluctuation. In a very 
fat abdomen there may be a wave on percussion, but this can usually be 
eliminated by the familiar method of applying the ulnar edge of the hand 
to the median line. 

An ascites may be quite difficult to distinguish from an ovarian cyst 
when the abdomen is completely filled with fluid. In the presence of mod- 




Fig. 366. — Early parovarian cyst. (Gynecological Laboratory, U. of P.) 

erate ascites, the differential diagnosis is quite easy, because, when the pa- 
tient is in the recumbent position there is bulging of the flanks, and the 
percussion note over the center of the abdomen is tympanitic, whereas in 
the flanks it is dull. The areas of dulness and resonance are altered by a 
change in the position of the patient ; that is, the dulness will disappear in 
one flank when the patient is turned and lies upon the opposite side, or, if 
the patient is made to stand erect, there will be dulness in the lower and 
resonance in the upper part of the abdomen. These differential signs are 
modified, however, when the ascites is sufficient in amount to completely 
distend the entire abdomen. In such cases there may be dulness over the 
entire abdominal surface, and a very distinct wave of fluctuation from one 
side to the other of the abdomen. If the ascitic fluid is not encysted there 
may be no resonance on percussion anywhere over the abdominal surface. 
If, as in case of ascites complicating peritoneal carcinomatosis or tuber- 



DISEASES OF THE OVARIES 



391 



culous peritonitis, the intestines are matted together and pushed to the 
periphery, so that they give coronal resonance, the simulation of an ovarian 
cyst may be almost absolute. In some cases a distinguishing feature 
between ascites and ovarian cyst is the recognition of peristaltic 
sound uniformly over the entire abdomen. In an ovarian cyst of large 
dimensions, these sounds would not be markedly audible over the greatest 
prominence of the tumor. Ovarian cyst with ascites may be suspected when, 
in addition to a fluctuating central tumor, there is a bulging of the flanks 
and a dulness over that region which is altered by change of position. Ascites 
may be expected in any case giving evidence of carcinomatous complications. 




/ \ \ 



U 



v \ 4 




Fig. 367. — Parovarian cyst. (Gynecological Laboratory, U. of P.) 



Parovarian Cysts. — Parovarian cysts are closely allied to ovarian cysts; 
they are epithelial new growths which in their etiology, symptomatology, 
and treatment resemble ovarian cysts ; they spring from the remains of the 
collecting tubules of the Wolffian system which lie between the layers of the 
broad ligament. The epithelium is almost invariably of the low columnar 
or cuboidal type, and the contents are serous. These cysts are usually uni- 
locular, and, as they originate from the parovarium, are therefore extraperi- 
toneal and intraligamentous, and are covered by peritoneum (Fig. 367). 
They grow to a considerable size, sometimes filling the entire abdomen, but 
they are less likely to be of gigantic proportions than the glandular cyst of 
the ovary proper. In their growth they are more or less restricted by the 



392 



GYNECOLOGY 



boundaries of the broad ligament, being resisted by the uterus on the inner 
side, the floor of the pelvis below, the pelvic wall on the outer side, and the 
attachment of the ovary to the tube and the infundibulo-pelvic ligament above 
(Figs. 366 and 367). During their growth they cause a displacement of the 
uterus to the side opposite that from which they spring, and an elongation 
of the Fallopian tube of the same side. The ovary itself is usually affected 
only by the pressure which is brought to bear upon it by the growing cyst, 
the ovarian tissue proper not being invaded or destroyed by the growth (Fig. 
373). These cysts are almost invariably unilocular. When they reach a large size 
thev are more distinctly and uniformly fluctuating than cysts of the glandu- 




Fig. 369. — Fibroma of ovary with partial intraligamentous development causing elongation of the tube. 
(Gynecological Laboratory, U. cl P.) 

lar type, and they have a pedicle formed by the broad ligament, the round 
ligament, and the tube. 

Symptoms. — Parovarian cysts occasion more symptoms in proportion 
to their size than glandular cysts of the ovary. This is because they develop 
between the layers of the broad ligament (Fig. 368) which holds them in 
the pelvis,- and between the uterus and the pelvic wall of the affected side 
(Fig. 373). The pressure upon the vessels and nerves of the broad ligament 
and upon the ureter of the diseased side, the flattening and displacement of 
the ovary, and the elongation and stretching of the tube, infundibulo- 
pelvic, and utero-ovarian ligaments may give rise to symptoms at an early 
stage. The symptoms consist of dull pain in the lower abdomen, back, or 
thighs ; disturbed menses, usually dysmenorrhea and menorrhagia ; blad- 
der irritability, frequent and painful urination, constipation, etc. The 



Say*"*'** 



,A»^ 




' t ''mesosalpinx 
"* 'tnesovarium 
* • Lig. Lat. uteri 




Fig. 368. — Diagram showing intra- and extraperitoneal position 
of cysts. 



DISEASES OF THE OVARIES 393 

severity and predominance of some of these symptoms above others depend 
upon the size of the tumor, the associated condition of the pelvic organs, 
and the individual peculiarities of the host. After a time, to the symptoms 
already mentioned, abdominal enlargement is added. Very rarely there are 
no symptoms until the tumor rises above the pelvic brim. 

Diagnosis. — The differential diagnosis of parovarian cysts from myomata 
of the uterus presents more difficulities than is the case with glandular cysts 
of the ovary. A parovarian cyst may be so tense and so intimately blended 
with the uterus as to be indistinguishable before exposure from a soft 
myoma. The detection of true fluctuation here may be the chief distin- 
guishing feature, and this is best elicited by the trimanual method of per- 
cussion (see page 130). Palpation of the ovary upon the surface of the cystic 
parovarian tumor may differentiate the parovarian from the ovarian cyst; 
and the recognition of the ovary entirely free and separate from a lateral 
tumor of the uterus, on the same side and of doubtful consistency, may 
distinguish a myoma. A parovarian cyst large enough to cause abdominal 
distention presents most of the features of the glandular ovarian cystomata al- 
ready given. Parovarian cysts of this size are usually very thin walled, regular 
in contour, and on palpation the resemblance to a tense ascites is very marked ; 
the distinguishing feature in such. a case would be the resonance surrounding 
the parovarian tumor (see also Chapter VIII, page 136). 

Papillomatous Cysts of the Ovary and the Parovarium. — A particular 
type of cyst, affecting either the ovary proper or the parovarium, is marked 
by the growth of wart-like masses, known as papillomata (Fig. 370). These 
papillomatous growths have a particular import in the ultimate state of the 
cyst, in the clinical symptoms, and in the prognosis ; in other words, a 
papillomatous cyst is always more of a menace to its host than a glandular 
cyst, because of its tendency to undergo malignant degeneration, and this 
occurs in about 50 per cent, of cases. 

Papillomatous growths may make their appearance in either ordinary 
glandular cystomata of the ovary of the serous type or in the cysts of the 
parovarium; or, it is alleged by some, even in the germinal epithelium of the 
Graafian follicle. They more commonly affect the ovary. Glandular ovarian 
or parovarian cysts, which become papillomatous or are papillomatous in 
the beginning, usually do not reach as large a size as the other forms. 
Papillomatous involvement usually takes place before the cyst has exceeded 
the size of an orange. Papillomatous cysts are much more frequently bilat- 
eral than unilateral ; they are not likely to contain cystic cavities of large 
size when they affect the ovary proper ; they are usually unilocular and of 
larger dimensions when parovarian in origin ; they are more likely to be 
solid or semi-solid when in the ovary proper ; they cause the death of their 
host with much more rapidity than do the other varieties. The papil- 
lomatous grow r th may begin either within the cyst or upon its outer surface 
(germinal epithelium). When the first appearance is within, the papil- 
lomatous masses sooner or later penetrate the wall of the cyst and involve 
its outer surface. After the wart-like growths become intraperitoneal, im- 
plantations occur upon neighboring parts of the peritoneum, intestine, omen- 
tum, or mesentery ; ultimately, the entire peritoneal cavitv becomes involved. 



394 



GYNECOLOGY 



It is said that extension of the papillomata to surrounding parts may take 
place without any malignant change in the papillomatous growth, and cases 
have been recorded in which, after the pelvic disorder was extirpated, papil- 
lomatous metastases on the peritoneum, or the abdominal organs, under- 
went regression and disappeared. It is quite likely that in many of the cases 
in which general involvement of the peritoneal cavity occurs there is a car- 
cinomatous degeneration of the papillomata, although this may be more or 




Fig. 370. — Papillomatous cystadenoma of ovary, with carcinatomatous degeneration in largest loculus. 
(Gynecological Laboratory, U. of P.) 

less confined to individual areas, and may possibly escape histologic exami- 
nation unless sections are taken from every part of the growth. They are 
much more apt to be accompanied with ascites, on account of the peritoneal irri- 
tation which they cause than are other forms of ovarian tumors. Rupture of a 
papillomatous cyst is especially injurious because of the danger of implan- 
tation of the warty growths throughout the abdomen. The irregular sur- 
face of papillary masses is sometimes felt through the vaginal vault. 

Symptoms of Papillomatous Tumors of the Ovary or Parovarium. — 
There are no characteristic symptoms of papillomata. The subjective indi- 



DISEASES OF THE OVARIES 395 

cations of their presence are more prominent than those of glandular cys- 
tomata of the ovary, or simple parovarian cysts ; ascites is more commonly 
present, and emaciation and weakness are more likely to be prominent 
features. The growths are found on both sides of the pelvis. Bimanual 
examination reveals pelvic masses of moderate size which give the impres- 
sion of being irregular and firmly fixed. Occasionally, however, the wart- 
like outgrowths may be definitely recognized (see Malignant Degeneration 
of Ovarian Tumors, page 407). 

Carcinoma of the Ovary. — Carcinoma of the ovary may be primary or 
secondary. The secondary carcinomas are either degenerated ovarian cysts 
or metastatic tumors from primary foci in the stomach, breast, intestine, 
gall-bladder, and uterus. Carcinomata of the ovary are more frequently 
secondary than has been commonly supposed. Primary carcinomata may be 
developed from epithelial inclusions derived from the Wolffian system. It 
is said that they may also originate in the germinal epithelium. Carcinoma 
of the ovary has a decided tendency to become bilateral. The 
tumors vary in size from that of a fist to that of a child's head. They are 
usually semi-solid, and on section present a honeycomb appearance — a 
meshwork of connective tissue, enclosing carcinomatous epithelium in solid 
plugs or in the form of glands filled with broken-down tissue and products 
of degeneration, of a cheesy or butter-like consistency. The size of the 
cystic spaces varies considerably, and there is often one space larger than 
the others. When the cystic feature is noticeable, the tumor is spoken of 
as medullary ; if the solid areas predominate, the tumor is classed as 
scirrhus. The surface of the tumor may be nodular or fairly even, and is 
often free from adhesions in the early stage. Before the tumors have 
reached any considerable size, the carcinomatous cells penetrate the capsule 
of the tumor, reach the surface, and then rapidly involve the general peri- 
toneum. Ascites and secondary carcinomatous tumors of the omentum, 
mesentery, intestine, and parietal ritoneum rapidly make their appear- 
ance. A fatal termination is usually not long deferred, due to the rapid 
growth of the original tumor, as well as to metastasis. 

Symptoms of Carcinoma of the Ovary. — Carcinoma of the ovary is the 
most insidious disease of the generative tract. In a large majority of cases 
the patient does not come under observation until she is incurable. A logi- 
cal conclusion from this statement, and a fact borne out by clinical experi- 
ence, is that there are often very few early symptoms. Frequently the first 
indication the patient has of anything wrong is an increase in size of the 
abdomen. The increase is due to the ascites and the secondary carcino- 
matous masses in the omentum. In such unfortunate cases careful ques- 
tioning will usually show that for some time there has been lower abdominal 
and pelvic pain and some disturbance of the bladder and bowels. There 
are usually no menstrual symptoms, as the patient has passed the menopause. 
In younger women there may be some menstrual irregularity and menor- 
rhagia. When the disease is advanced there is abdominal enlargement, 
pelvic and lower abdominal pain and soreness, constipation, and digestive 



396 GYNECOLOGY 

disturbance. The patient loses weight and strength rapidly. Pelvic ex- 
amination in such a case discovers irregular, indurated masses in Douglas" 
pouch ; the bases of the broad, uterosacral, and uterovesical ligaments feel 
thickened and indurated ; the cervix is small and fixed ; it may be impossible 
to outline the body of the uterus, as satisfactory bimanual examination is 
prevented by the ascitic distention. The abdomen may be distended uni- 
formly, or the lower abdomen may be principally or exclusively affected. 
In the first case the ascitic fluid is free ; in the second it is encysted and 
surrounded by a wall of carcinomatous omentum, intestine, and parietal 
peritoneum. In either case irregular indurated masses may be palpated 
through the abdominal parietes. Fluctuation may be present over the entire 
abdominal tumor, or it may be limited to certain areas. If the ascitic fluid 
is encysted, there is dulness over the summit of the abdominal enlargement 
and resonance or tympany surrounding it. When the ascitic fluid is free 
and the abdomen is not tensely filled, there may be tympany in the center 
of the abdomen with dulness in the flanks and above the pubes. The areas 
of dulness change with the position of the patient (see also page 134). 

CONNECTIVE-TISSUE NEW GROWTHS 

The connective-tissue tumors of the ovary may be classified as benign, 
fibromata, or malignant — sarcoma, endothelioma, perithelioma. Connec- 
tive-tissue tumors of the ovary are much less frequent than cystic tumors. 

Fibromata of the Ovary. — Fibromata of the ovary are not frequent. 
The smaller ones are localized projections of ovarian stroma caused by a 
cicatricial contraction at the site of a previously existing corpus luteum. 
Fibromata of a larger size are due to a real proliferation of the ovarian con- 
nective tissue, and involve the entire ovary (Fig. 369). They may become 
very large, even as large as a pregnant uterus at the sixth month. They 
vary considerably in gross appearance. Usually they are rather dense, the 
capsule is whiter than that of a uterine fibroid, and, on section, the tumor 
exhibits areas of cystic degeneration or necrosis. Fibromyomata are less 
frequent than pure fibromata, and have in addition to fibrous tissue a few 
muscle-fibers. Both fibromata and fibromyomata are usually unilateral. 
Sarcomatous degeneration of the spindle- or the round-cell variety of fibro- 
mata has occasionally been found. The symptoms they produce are usually 
due to mechanical conditions brought about by weight and pressure. Be- 
cause of the irritation which the tumor produces by rubbing the peritoneum 
in its vicinity, there is often an ascites. A solid tumor of the ovary, accord- 
ing to some authorities, is subject to torsion more frequently than other 
forms of tumor. It gives the same physical signs and symptoms as a cystic 
tumor of a corresponding size, with the exception that it is hard and does 
not give fluctuation. 

Sarcomata of the Ovary. — Sarcoma of the ovary is one of the rarest new 
growths of that organ, constituting but 2 per cent, of ovarian tumors, and 30 
per cent, of these are bilateral. At times sarcoma of the ovary is secondary 
to sarcoma in various other organs, as the pancreas, kidney, stomach, lymph- 
glands, and thyroid. Sarcomata of the ovary may be of the spindle- or round- 
cell variety Particular forms of endo- and peri-theliomata may occur. A 



DISEASES OF THE OVARIES 



397 



mixed tumor of sarcomatous and carcinomatous elements, often with mucoid 
degeneration, has been occasionally observed. This type of tumor, described 
by Kruckenberg, is usually secondary to gastric or mammary carcinoma. 

COMBINED EPITHELIAL AND CONNECTIVE-TISSUE TUMORS 

Tumors in which epithelial and connective-tissue new growth are combined 
belong to the teratomas. Teratomata of the ovary are commonly cystic because 
of the greatly preponderating amount of epithelial and glandular tissue which 
they contain (Fig. 371). The epithelium and glandular tissue resemble those of 
the skin, and, because of this structural peculiarity, such tumors are com- 
monly spoken of as " dermoid cysts." 

Dermoid Cysts of the Ovary. — The origin of dermoid cysts of the ovary 
has been a matter of interest and much speculation. Wilms believed that 
they represented the abortive development of an unfertilized ovum. He 




Fig. 371. — Dermoid cyst of ovary. (Gynecological Laboratory, U. of P.) 

based his theory partly upon the predominance of the ectodermoid tissues 
which develop earlier than other tissues in the normal fcetus. The observa- 
tions of Bonnet and others have shown, however, that all these tumors con- 
tain the elements of each of the three layers of the blastoderm, and it is 
much more likely that they represent blastomeres which have become dis- 
placed during the early development of the ovum, and subsequently lodged 
within the Wolffian system w T hich occupies a large part of the early embryo. 
Dermoid cysts are lined with a skin-like membrane possessing hair, seba- 
ceous and sw r eat glands. Elementary maxilla, teeth, and other structures, 
such as ganglion cells, rudimentary intestine, cartilage, thyroid tissue, etc., 
are found in a thickened area of the cyst wall, or in a solid part of the tumor. 
This solid part usually projects into the cyst cavity, and is called 
the dermoid eminence. The cyst content is usually a buttery or cheesy 
semi-liquid material, containing the shed hair from the skin lining, 
and composed of the oily excretion from the shafts of the hair glands, or 



398 



GYNECOLOGY 




Fig. 372. — Ovarian teratoma with histologic sketches of tissue: (A) Primordial follicle in ovarian stroma; 
(B) struma colloides; (C) Mucous glands; (D) sebaceous glands. (Anspach in University of Pennsylvania 

Medical Bulletin.) 



DISEASES OF THE OVARIES 399 

sebaceous material excreted by the sebaceous glands. At the body tem- 
perature this fatty content is semi-liquid, but on exposure to cold it partly 
solidifies, and sometimes the contents may be so thick, even at body tem- 
perature, that it is semi-solid. Dermoid tumors are usually intraperitoneal, 
although they may develop between the layers of the broad ligament. They 
are, as a rule, of moderate size, hardly ever being larger than a grapefruit, 
and practically never reaching the huge dimensions of the glandular cysts. 
Owing to the thinness of the wall and the yellowish contents, the surface of 
the tumor is often yellow. It may, however, be of a pearl-gray color, due either 
to an unusual thickness of the capsule or to whiter and more cheesy contents, 

Sometimes the so-called dermoid cyst does not contain much ectodermal 
tissue ; its structure then approaches that of the ordinary teratomata. In 
some tumors of this type there is a large proportion of thyroid-gland tissue ; 
such a tumor is spoken of as struma ovarii, Fig. 372. Pick mentions " hydatidi- 
form-mole-like " structures in a case of dermoid cyst. Teratomatous tumors of 
the ovary are the most common variety of ovarian tumor found in the young, 
some cases being reported before the age' of puberty. They appear most 
often, however, during the active childbearing period, though they may 
make their appearance in the aged. Dermoid cysts of the ovary often occupy 
a position anterior to the uterus, instead of posterior, as one might expect. 
Dermoid cysts are often adherent, sometimes forming attachments to neigh- 
boring hollow viscera, into which they break and discharge their secretion. 
Rarely dermoid cysts may be complicated by the development of carcinoma 
in their epithelium constituents. 

Symptoms. — The symptoms of dermoid cysts of the ovary are not at all 
characteristic, but, as a rule, they cause more disturbance in proportion to 
their size than the glandular cystomata. They very rarely are large enough 
to cause an abdominal tumor, and are evidenced more by pain and distress 
in the lower abdomen and back, vesical and rectal disturbance, and men- 
strual disorders. Dermoid cysts are more often complicated by inflamma- 
tion of the surrounding peritoneal surfaces than any other of the benign 
ovarian tumors. 

Pelvic examination may give no inkling of their true nature, the ex- 
aminer progressing no further than the diagnosis of an ovarian cystic tumor. 
Occasionally, however, the contents being unusually thick and the cyst less 
tensely filled than usual, there may be a doughy sensation imparted to the 
examining finger. 

TREATMENT OF OVARIAN NEW GROWTHS 

Cystomata. — The treatment of a cystic new growth of the ovary should 
always be surgical — that is to say, as soon as the diagnosis is made, provided 
the general condition of the patient permits, an operation for its removal 
should be undertaken. Immediate, or comparatively immediate, operation 
is indicated for the reason that these tumors show little or no tendency to 
undergo a spontaneous cure, their growth is usually unlimited and unre- 
stricted, they progressively sap the patient's strength and resistance, and 
they may, at any time, become the subject of accidents, such as will be 
described. Furthermore, carcinomatous degeneration is comparatively frequent 



400 



GYNECOLOGY 



The operation of removing an ovarian cyst, in uncomplicated cases, is 
very simple and easy. In intraligamentous cysts, however, or in those 
complicated by inflammation and adhesions, the operation may be extremely 
difficult. Usually, the operation consists of a simple median incision, evacua- 
tion of the contents of the largest cyst cavity by means of a trocar, delivery 
of the collapsed cyst through the incision, and ligation of the pedicle. If 
there is any reason to suspect malignant degeneration, or any form of intec- 
tion, or, if the tumor is of the papillomatous variety, it is better to avoid 
puncture and aspiration, and to make an abdominal incision of sufficient 
length to deliver the tumor without aspirating it. 

Intraligamentous tumors (Fig. 373) may sometimes present consider- 
able difficulty in the way of operation, especially if they are of the papil- 




O^ ViJtfeV-\JLS 







Fig. 373. — Displacement of uterus and stretching of tube in pelvic intraligamentous tumor. 



lomatous type, or if they are complicated by carcinomatous changes. 
An attempt may be made to enucleate the tumor by securing the 
ovarian vessels at the pelvic brim and at the uterine cornua, and then 
incising the peritoneum and shelling the growth from between the layers 
of the broad ligament. If the tumor is firmly fixed and this plan appears 
impracticable, and especially if the patient is approaching the menopause, a 
hysterectomy is advisable in order to facilitate the detachment of the lower 
pole of the tumor from the base of the broad ligament, the excision being 
started on the side opposite the growth, and the tumor itself being attacked 
from below, after cutting through the cervix. 

The question of performing bilateral salpingo-oophorectomy and hyster- 
ectomy in connection with the removal of an ovarian cyst is important in 
direct proportion to the probability of the ovary of the opposite side becom- 



DISEASES OF THE OVARIES 401 

ing diseased. Cases have repeatedly occurred in which ovarian cysts have 
developed in both ovaries, in the second one a number of years after the 
first ovary had been removed. For this reason, in patients approaching the 
age of forty, it is usually advisable to remove the uterus and the opposite 
ovary, unless they present an absolutely normal appearance, and in women 
over forty, it is advisable to remove the uterus and both adnexa, whether 
the opposite ovary appears diseased or not. 

Papillomatous tumors of the ovary are especially liable to be bilateral, 
and, when dealing with them, the surgeon will do well who leans to the radi- 
cal side and removes the opposite ovary upon the least suspicion of involve- 
ment. In young women, if the second ovary appears absolutely normal, it 
may be let alone, and the case carefully watched. On the least indication of 
subsequent involvement another operation should be undertaken. 

Operation for papillomatous tumors of the ovary will sometimes lay bare 
a papillomatous involvement of the peritoneum, appendix, and intestines. 
These papillomatous implantations or metastases are not invariably malig- 
nant, and the surgeon need not feel that the case is hopeless because he is 
unable to remove them. Sometimes after the papillomatous ovarian dis- 
ease has been extirpated, such masses will disappear ; their existence, how- 
ever, always makes the outcome dubious, and the prognosis should invari- 
ably be guarded. 

Ovarian tumors discovered during pregnancy should be exposed to 
operation. It has been shown by Norris and others that the expectant 
treatment of an ovarian tumor discovered during pregnancy carries a dan- 
ger to the mother three times as great as that of early operation. In twenty- 
two cases, reported by Wiener and Cathola, removal of the tumor was fol- 
lowed by abortion or premature labor in but four. During the operation 
the parts should be handled as gently as possible, and the post-operative 
treatment should be like that adopted for threatened abortion. If the cyst 
is discovered near term, and there are no symptoms, the operation may be 
delayed until that time, when Caesarean section and an oophorectomy may 
be combined. 

Carcinomata. — Carcinoma of the ovary in the early stage demands a 
complete hysterectomy and the removal of both adnexa. The entire uterus 
must be removed because the endometrium may show a metastatic growth, 
or because it is possible that the ovarian carcinoma is secondary to an un- 
recognized cancer of the uterine body. The opposite ovary and tube must 
be taken away because of the pronounced tendency of the ovary of the oppo- 
site side to become carcinomatous. If the celiotomy incision shows that 
there are extensions to the pelvic peritoneum, sigmoid, etc., and if supra- 
vaginal hysterectomy with bilateral salpingo-oophorectomy presents no 
extraordinary technical difficulties, this plan should be carried out, the im- 
plantation growths upon the peritoneal surfaces being cauterized as far as 
practicable with the thermocautery. Some cases of papillomata answering 
this description have gotten well even though the surgeon has been obliged 
to close the abdomen, leaving portions of the growth diffusely spread upon 
the adjacent peritoneal surfaces and organs. It may be that the cases which 
terminate favorably are not carcinomatous; one can not say always from 
26 



402 GYNECOLOGY 

the gross appearance of the involved areas, whether the disease is benign or 
malignant. Therefore, it is wise to give the patient the benefit of the doubt, 
remove all the diseased structures that it is technically possible to remove 
without running too great a risk, and then use the Rontgen ray or radium in 
the subsequent treatment. 

In the late stage of carcinoma of the ovary, nothing is possible surgi- 
cally, the masses in the pelvis cannot be extirpated with safety, and the 
extension of the disease to the omentum, mesentery, intestines, and visceral 
organs makes any surgery hopeless. Nevertheless, except in the most 
advanced cases, an exploratory incision should be made. Now and then a 
case which appears hopeless before an incision is made may, nevertheless, 
be saved by operation. 

Fibromata. — Small fibromata of the ovary may be excised from the ovary 
if a healthy part of that organ is demonstrable. Large fibromata, or those 
in which the entire ovary is involved by the growth, demand a complete 
oophorectomy. The tube may be saved if it is healthy and its conservation 
presents no technical difficulties. 

Sarcomata. — The treatment of sarcoma of the ovaries is identical with 
that described for carcinoma of the ovary. 

RETENTION CYSTS OF THE OVARY 

In addition to the ovarian tumors that have been mentioned, cystic and 
solid, other tumors of the ovary of a cystic nature may result, not from an 
actual growth and development of epithelium, but from the retention within 
the ovary of fluid, which, under normal conditions, is either expelled or ab- 
sorbed. They are spoken of as retention cysts, or as cystic degeneration. 

Graafian Follicle Cysts. — A simple retention cyst of the ovary affects the 
Graafian follicle. It scarcely ever reaches a very large size, rarely beyond 
that of an orange. Occasionally, a cystic condition of several Graafian 
follicles in the same ovary may exist, under which circumstances, as the 
cysts increase in size, the intervening septa may be destroyed, so that they 
finally merge into one. When the cyst cavity is of considerable size and 
has evidently come from the distention of one, or at most several follicles, 
the condition is spoken of as hydrops folliculi. If many Graafian follicles 
undergo cystic degeneration coincidently, and none of them reaches a very 
large size, the ovary may be honeycombed with these small cystic spaces, 
and the condition is then termed cystic degeneration of the ovary. 

Cystic degeneration of the ovary may be the result of a thickening of 
the ovarian capsule by perioophoritic exudate or adhesions. In some cases 
the increased thickness and density of the capsule appear to be independent 
of previous perioophoritis. Frankl believes that cystic degeneration of the 
ovary is the result of a premature and abortive development of a large num- 
ber of follicles at the same time, induced by chronic hyperemia (inflamma- 
tion, circulatory disturbance, etc.). 

A hydrops folliculi is usually unilocular, the outer surface being perfectly 
smooth and free of attachment to surrounding organs ; the wall is thin and 
the contents usually clear serum, unless hemorrhage has occurred into the 



DISEASES OF THE OVARIES 



403 



cyst cavity, when the fluid may be a chocolate brown. The outer surface is of 
a dead white color, corresponding to the tunica albuginea. The unaffected 
part of the ovary is usually found to one side of the cyst cavity, the amount 
of unaltered ovarian tissue present depending upon the number of follicles 
which have been involved in the formation of the cyst. 

A corpus luteum cyst (Fig. 374) results from the failure of absorption of 
the fluid blood in a Graafian follicle during the formation of the corpus 
luteum, or from a replacement of the absorbed blood by clear transuded 
blood serum. A corpus luteum cyst usually does not reach as large a size as a 
hydrops folliculi; its wall is comparatively thick, its color often purplish 
red or chocolate brown, although it may present the dead-white appearance 
of the tunica albuginea, or the yellowish color of the lutein cells. The 
surface of the ovary containing a corpus luteum cyst is usually free of adhe- 
sions unless infection has preceded or followed it, or the tumor has attained 
such a size as to cause irritation of the sur- 
rounding peritoneum. 

Symptoms of Graafian Follicle and 
Corpus Luteum Cysts. — Cystic degenera- 
tion, of the ovary, hydrops folliculi, and 
corpus luteum cysts are, as a rule, but a 
part of chronic pelvic peritonitis, the symp- 
toms of which are detailed on page 429. 
The ovarian abnormalities may be the most 
prominent feature of the residuum of a 
previously acute pelvic peritonitis, the other 
evidences of the inflammatory process hav- 
ing nearly or entirely disappeared. The 
symptoms are menstrual disorder of some 
type — too frequent or delayed periods, with 
increase or diminution of the flow, depend- 
ing upon the effect of the disease upon the 
ovarian secretion. The menses may be 
painful ; the distress is usually most marked during the week of premenstrual 
congestion and subsides as the flow develops. Added to these symptoms peri- 
odic evidences of disorder may be manifested, such as low abdominal pain on 
the affected side, dyspareunia. and dyschesia. 

Diagnosis. — The ovary which is the seat of a Graafian follicle or corpus 
luteum cyst is enlarged, possibly tender, and often fixed in position by adhe- 
sions. The uterus may be outlined and sharply defined on one side and in 
front. The size of the enlargement rarely exceeds that of a lemon ; it is 
globular or spherical in shape. In exceptional cases, when the ovary is as 
large as an orange (hydrops folliculi), fluctuation may be detected. When 
the ovary is not adherent, a freely mobile, semi-elastic, globular tumor con- 
nected by a pedicle to the uterus is almost characteristic. If, however, the 
ovary is adherent, the trouble may be difficult to distinguish from a tubal 
enlargement, and it is not uncommon to find the tube adherent and closely 
attached to the enlarged ovary. 

Treatment. — The attitude of the surgeon toward simple retention cysts 




Fig. 374. — Corpus luteum cyst of ovary. 
(Gynecological Laboratory, U. of P.) 



404 GYNECOLOGY 

of the Graafian follicle and the corpus luteum, and toward cystic degenera- 
tion of the ovary should be quite different from that which he must assume 
to ovarian new growths. These ovarian affections may be distinguished 
chiefly by their smaller size, although, occasionally, the diagnosis will be 
impossible until an abdominal incision has been made. 

If two-thirds of the ovary are uninvolved, a cyst of a corpus luteum or of a 
Graafian follicle may be removed by incising the tunica albuginea at the 
junction of the cyst with the unaffected ovarian tissue, shelling out the 
capsule of the cyst from the ovarian stroma, and closing the raw area by 
approximating the sides with fine sutures. If less than two-thirds of the 
ovary remains unaffected, the treatment will depend upon the condition of 
the opposite ovary. If the latter appears to be perfectly healthy, the af- 
fected ovary should be removed ; if both ovaries are about equally involved, 
resection should be undertaken. 

The surgeon's attitude toward cystic degeneration of the ovary should 
differ somewhat from that toward follicular or lutein cysts. In cystic 
degeneration of the ovary the prognosis from resection is much less favor- 
able than in hydrops folliculi. If but one ovary is extensively affected 
it will be advisable to remove that ovary entirely. If both ovaries 
are equally affected, and the woman is youthful, an attempt should be made 
to cure the patient by resecting a portion from each. In making this resec- 
tion the surgeon's aim should be to make flaps which will approximate with- 
out much difficulty. The portion excised should be principally from the 
cortical area, and should occupy a central position, running from pole to 
pole rather than from side to side. In this way more of the follicle-bearing 
area, which is the site of the disease, may be removed, and with less dis- 
turbance to the ovarian circulation than if the hilus of the ovary is involved 
by the excision. The sides of the ovary should then be approximated by 
through-and-through sutures of fine catgut, passed with a round-pointed 
needle, and tied sufficiently tight to secure hsemostasis and cover up raw 
surfaces. The fewer sutures needed, the better will be the outcome of the 
case ; absolute hsemostasis is indispensable to success. 

Compound Theca-lutein Cysts of the Ovary — Lutein Cystoma Ovarii. — 
In a large number of cases of hydatidiform mole or chorionic epithelioma, 
the ovary has been found to be the seat of a multilocular cystic formation, 
usually bilateral. The size of such cystic ovaries varies; they have been 
observed as large as the foetal head. The cysts resemble those derived from 
the corpus luteum in that the wall is made up of layers of lutein cells of 
varying degrees of thickness. There is also a diffusion of lutein cells in the 
ovarian stroma. The cyst content is fluid, semi-fluid, or opalescent, although 
often stained by hemorrhage. These cysts have been observed to undergo 
retrogression after the removal of the intra-u;erine mole formation. Vari- 
ous speculative theories as to their origin have been advanced. Whether 
over-activity of the chorion epithelium produces an excess of lutein tissue 
with subsequent cyst formation, or whether over-activity of the lutein tissue 
governs the overgrowth and cystic degeneration of the chorion villi re- 
mains to be determined. No recorded specimens have shown malignant 
degeneration. The diagnosis is usually made by histologic examination. 
The majority of cases have been treated surgically. 



DISEASES OF THE OVARIES 405 

ACCIDENTS AND COMPLICATIONS OF OVARIAN TUMORS 

Cystic ovarian tumors are subject to infection, intracystic hemorrhage, 
torsion of the pedicle, and rupture. Solid ovarian tumors are subject to 
torsion of the pedicle. 

Infection. — Infection of ovarian cysts is more common in the dermoid 
than in the other varieties, and is more frequent in tumors which have been 
subjected to tapping, or in those whose blood supply has been impaired by 
torsion of the pedicle, traumatism, or intracystic hemorrhage. Unless such 
predisposing causes obtain, infection is unusual. Infecting organisms may 
reach ovarian cysts by extension from neighboring intestine, through the 
Fallopian tubes, the blood, or the lymphatics of the broad ligament. Infec- 
tion of ovarian cysts by the typhoid bacillus has been observed as a com- 
plication of typhoid fever. Infection is particularly apt to occur following 
the trauma incident to abortion or labor. 




Fig. 375. — Ovarian cyst twisted on its pedicle. (Gynecological Laboratory, U. of P.) 

The symptoms of infection of an ovarian cyst are largely those which 
characterize an ovarian abscess ; the tumor may, or may not, have been 
recognized previously. If the physician or patient has been aware of its 
presence, there may be a demonstrable increase in size ; the abdominal 
muscles exhibit spasm and rigidity, and on palpation the tumor itself, pre- 
viously insensitive to pressure, may have become exquisitely tender. In 
addition, there are the general symptoms — fever, increase in the pulse-rate, 
possibly chilly sensations, and indications of toxsemia. There may be con- 
siderable spontaneous pain in the pelvis or abdomen. 

If the tumor has been unsuspected, the existence of a cystic mass at the 
very beginning of the attack will be suggestive of its true nature. The 
physical signs and the objective symptoms previously described will fur- 
nish further positive evidence. 



406 



GYNECOLOGY 



Acute infection of a cyst may be difficult to distinguish from torsion. As 
a rule, torsion is accompanied with more acute pain and less febrile disturb- 
ance, at least in the early stages. While the leucocyte count in torsion in- 
creases slowly acute infection will be accompanied by an earlier and 
higher leucocytosis. 

Torsion. — Torsion of the pedicle of an ovarian tumor is the most fre- 
quent accident to which these growths are subject. Tumors of moderate 
size (lemon to a grapefruit), non-adherent, and with a smooth surface are 
predisposed to torsion (Figs. 375 and 376). Fibromata of the ovary become 
twisted with relatively more frequency than cystic ovarian tumors ; but 




. 




Fig. 376. — Ovarian cyst with torsion of its pedicle. (Bryn Mawr Hospital.) 



torsion of a fibroma is not often observed inasmuch as these growths are 
comparatively rare. Glandular cystomata are more likely to undergo torsion 
than any other variety of cyst ; torsion is least likely to occur in parovarian 
cyst. This complication is not infrequent in dermoid cysts. Papillo- 
matous and malignant cysts rarely undergo torsion, as they are usually more 
or less fixed and adherent. It goes without saying that any cyst complicated 
by adhesions cannot undergo torsion ; but a cyst which has undergone tor- 
sion becomes adherent unless removed, as a result of the nutritional dis- 
turbances in its outer wall. Factors favoring torsion of the pedicle of an 
ovarian tumor are a tumor of moderate size and smooth surface, a roomy 
pelvis, and a relaxed abdominal wall. Rotation may be precipitated by the 
act of urination or defecation, by falls, and by sudden, excessive muscular 
effort. 



DISEASES OF THE OVARIES 407 

The symptoms of acute torsion are sudden and severe pain in the abdo- 
men or pelvis. The pain is usually agonizing in character, and hard, to 
relieve. The patient may, or may not, have been conscious of a tumor be- 
forehand. If she has been aware of its presence it may be apparent that the 
tumor is somewhat increased in size and has become sensitive to pressure. 
The pain may radiate in different directions beyond the seat of the growth 
and may give rise to reflex disturbance, such as nausea and vomiting. Al- 
though the temperature may be subnormal at first, before long fever makes 
its appearance and a moderate increase in the pulse-rate is present from 
the beginning of the attack. If the patient is not relieved by surgical meas- 
ures the pain has a tendency, after a few days, to subside, this being the 
signal of necrosis of the pedicle and tumor, with the formation of adhesions 
about the growth, and possibly the beginning of a circumscribed peritonitis. 
Infection, also, may supervene. 

Rupture of an ovarian cyst usually follows traumatism of some sort. It 
has followed a fall or a blow upon the abdomen, a fall upon the buttocks, 
violent straining at stool, and other causes which may suddenly increase 
intracystic tension. Ruptures are accompanied by the following symp- 
toms : Sharp pain over the affected area ; diminution in the size of the tumor ; 
free fluid in the abdominal cavity, and, in some cases, symptoms of internal 
hemorrhage so marked, even from the rupture of a corpus luteum cyst, as 
to simulate a ruptured ectopic pregnancy. A number of such cases have 
been reported in which the true state of affairs was found only at the time 
of operation. The result of the escape of the contents into the peritoneal 
cavity depends upon the nature and complications of the cyst. A thin, 
serous or mucinous collection of fluid may be absorbed in the course of a 
few days, while a thick pseudomucinous collection in the peritoneal cavity 
may give rise to a foreign body peritonitis with attempted encapsulation of 
the pseudomucinous material. In the latter event the parietal peritoneum 
and serous covering of the intestine are diffusely reddened and thickened. 
Close examination will show minute particles of pseudomucin embedded in 
the thickened peritoneal coats. To this condition the name of pseudo- 
myxoma peritonei was given by Werth. If at the time of rupture some of 
the pseudomucinous cells lining the cyst have become transplanted to the 
peritoneal cavity, or if the opening between the cyst cavity and the peri- 
toneal cavity persists, the amount of pseudomucinous material may gradu- 
ally increase. If the condition is unrelieved by operation, death may ensue. 
When papillomatous debris is discharged into the peritoneal cavity, it 
causes a foreign body peritonitis with, at first, attempted encapsulation 
and, ultimately, transplantation of the papillomata. The vegetations soon 
involve all the neighboring serous surfaces and may spread throughout the 
abdominal cavity. Papillomata peritonei become malignant in 50 per cent, 
of cases, and cause death in a large proportion of those affected. 

Malignant degeneration of ovarian tumors is by no means rare. It is 
often hard to determine whether a given malignant growth involving the 
ovary is primary or secondary. The difficulty in making such a distinction 
is evident. The fact remains, however, that a considerable proportion of 
ovarian tumors are malignant. Norris found ten out of sixty-three cases 



408 GYNECOLOGY 

malignant, and judged that four of the ten were originally benign. Wiener 
found twenty-four carcinomata in 269 ovarian tumors ; five of the twenty-four, 
he believes, were originally benign. Carcinomatous degeneration is par- 
ticularly likely to affect papillomatous and serous cysts. In a large propor- 
tion of cases when a papillomata has extended from the ovary to the peri- 
toneum it has already begun to undergo malignant degeneration. It is only 
by histological examination that early malignant changes in these tumors 
can be detected. In the later stages the papillomatous masses are under- 
laid by hard plaques of infiltrating cells which invade the cyst wall. Car- 
cinomatous degeneration of serous or pseudomucinous cysts is usually indi- 
cated grossly either by the development of papillomatous masses situated 
upon indurated areas in the cyst wall, or by solid areas of considerable indura- 
tion which encroach upon the more cystic parts of the growth. A squamous-celled 
type of carcinoma is found as a complication of dermoid cysts. Fibroma and 
fibromyomata of the ovaries may undergo sarcomatous degeneration. 

Carcinoma of the ovaries, due to metastasis from other organs, often 
appears after ascites and general peritoneal involvement have hidden the 
original tumor. The primary location of the disease may be difficult or im- 
possible to discover. In may be found in a small carcinomatous intes- 
tinal lesion, or an unsuspected nodule in the breast. Metastatic cancer of 
the ovary is bilateral in 50 per cent, of the cases, according to Frankl. As 
a rule, it is of a scirrhous type, and is smaller than the primary 
medullary forms. 

TREATMENT OF THE ACCIDENTS WHICH MAY OCCUR TO OVARIAN CYSTS 

Torsion. — An ovarian cyst which has undergone torsion requires oper- 
ative removal without delay. Any other course will expose the patient to 
the risk of necrosis and gangrene of the tumor, extensive adhesions, and 
possibly a spreading peritonitis. 

Rupture. — Immediate celiotomy is indicated with extirpation of the 
growth ; otherwise the patient is exposed to the danger of uncontrolled 
internal hemorrhage, and the escape of irritating malignant contents into 
the peritoneal cavity. 

Infection. — If the diagnosis is positive, immediate operation with ex- 
tirpation of the infected cyst should be undertaken. The only cases which 
admit of delay are those in which the tumor is small and there is difficulty 
in distinguishing between an infected ovarian cyst and pelvic inflammatory 
disease of the post-partal, post-abortal, or gonorrhceal types. If, under 
such circumstances, the usual palliative measures result in no improvement, 
an exploratory operation is justifiable. 

Malignant Degeneration.— The treatment is that already outlined for 
carcinomatous tumors of the ovary. 

MISCELLANEOUS LESIONS OF THE OVARY 

Atrophy of the Ovary. — The ovary may undergo premature atrophy as 
the result of damage wrought by pelvic inflammatory diseases, or by the 
pressure of uterine or parovarian tumors. Atrophy may also follow 
oophoritis caused by infectious diseases, particularly scarlet fever, parotitis, 



DISEASES OF THE OVARIES 409 

or varioloid. In addition, it has been observed in the course of syphilis, 
diabetes, myxoedema, exophthalmic goiter, locomotor ataxia, acromegaly, 
and poisoning by arsenic and phosphorus. In some women, in the early 
thirties, atrophy of the ovary occurs without any apparent cause and is 
usually associated with a pronounced increase in adipose tissue throughout 
the body. In the various anaemias either primary or secondary to general 
diseases such as tuberculosis, the ovary may undergo atrophy. The symp- 
toms are a gradual or sudden diminution in the menstrual flow, together 
with the nervous manifestations usually reserved for the menopause. 

Hypertrophy of the Ovary. — The ovary may be generally enlarged with- 
out being cystic or the seat of new growths. 

This condition is most often observed in connection with fibroid tumors 
of the uterus. 

Hernia of the Ovary.— The ovary may occupy a place in a hernial sac. 
This is most common in connection with inguinal hernia, but may occur in 
the femoral or the obturator varieties. The hernia is often congenital. The 
displacement of the ovary may be bilateral. In the course of time, adhe- 
sions may occur between the ovary and the sac ; the ovary, being unnatur- 
ally exposed to traumatism, may be injured, so that interstitial hemorrhage, 
inflammation, and solid or cystic hypertrophy may occur. The distinguish- 
ing feature of the hernia is the sensitive mass which is commonly irre- 
ducible, swells at each menstrual period, and at that time becomes unusu- 
ally painful. The diagnosis is facilitated by finding the fundus of the uterus 
inclined toward the side of the hernia. The treatment is always surgical, 
and consists in freeing the ovary from the hernial sac, dividing the hernial 
ring, replacing the ovary, and performing the usual radical operation for 
the cure of the hernia. In some cases it is impossible to free the ovary 
without seriously damaging its surface to such an extent that if it were 
replaced within the abdomen, adhesions or other pathological processes 
would be sure to occur. Under such circumstances the ovary must 
be extirpated. 

Prolapse of the Ovary. — Prolapse of the ovary is usually a mere accom- 
paniment of a backward displacement of the uterus. Rarely it may be in- 
dependent of the position of the uterus. Under such circumstances, the 
uterus may be in a normal position, but the utero-ovarian and the infundi- 
bubo-pelvic ligaments are elongated and relaxed. The symptoms of pro- 
lapse of the ovary are pain on the affected side, especially when the patient 
is upon her feet or performing some bodily exertion ; pain upon 
defecation, and dyspareunia. Upon examination the ovary will be found 
lying in Douglas' pouch, where it can be readily felt by simple digi- 
tal examinatin. The displacement of the ovary may be accompanied 
by displacement of the uterus, or the uterus may be in a normal posi- 
tion. Prolapse of the ovary, dependent upon displacement of the uterus, 
is cured by correcting the position of that organ. Prolapsus of the 
ovary occurring alone may be dealt with by the assumption of the knee- 
chest position regularly, and by the use of tampons, daily laxatives, and hot 
douches. In most cases, however, prolapse of the ovary will ultimately re- 
quire some operative treatment, although uncomplicated cases of prolapse 



410 GYNECOLOGY 

of the ovary are very rare. The operation consists of : suspending the ovary 
to the round ligament by passing a suture through the mesosalpinx, catch- 
ing the hilus of the ovary and the round ligament, 1 or plication of the in- 
fundibulo-pelvic ligament.. Any of the operations for suspension of uterus 
will correct a coincident displacement of the ovary. The Webster-Baldy 
operation especially is effectual. 

BIBLIOGRAPHY 

Anspach, B. M. : " The Present Conception of Dermoid Cysts of the Ovary." U. of Pa. 

Med. Bull., 1903, Nov. 
Bandler : Die Dermoidcyste des Ovarium. Berlin, 1900. 
Bonnet: " Aetiologie d. Embryoma." Monat. f. Geb., 1900. 
Briggs, H. : " Unilateral Solid Primary Adenoma of Ovary." Proc. Royal Soc. Med., 1916, 

ix, 73- 
Clark, J. G. : "The Histogenesis of Glandular Cysts of the Ovary." Trans. Amer. Gyn. Soc, 

1903, xxviii, 312. 
Davis, C. H. : "A Contribution to the Etiological Study o_f Ovaritis." Surg., Gynec. and 

Obst., 1916, 560. 
Frankl : " Pathologische Anatomie u. Histologic der Weiblichen Genitalorgane." Leip- 

mann's Handbuch des Gesammt, Frauenheilkunde, vol. i, Vogel, Leipzig, 1914. 
Griffith and Williamson, H. : "Diseases of the Ovary." System of Gynecology, Albutt, 

Playfair and Eden, Macmillan & Co.. Lo;ndon, 1909. 
Hofmeier : " The Latest Results of Ovariotomy, Especially in Cases of Doubtful Charac- 
ter of the Disease." Trans. Am. Gyn. Soc, 1909, 333. 
Jones, W. C. : " Etiology, Pathology and Treatment of Ovarian Cysts." Surg., Gyn. and 

Obst., 1913, xvi, 63. 
Kruckenberg, G. : " Uber des Gleichzeitige Vorkommen von Carcinom u. Dermoidcyste in 

ein und Demselben Ovarium." Arch. f. Gynak., 1887, xxx, 241. 
MacCallum, J. B. : " Notes on the Wolffian Body in the Higher Mammals." Am. Jour. 

Anat, 1901-2, i, 225. 
Norris, C. C. : "A Clinical Study of the Complications Arising in 63 Consecutive Cases of 

Ovarian Tumor with Especial Reference to Malignancy." U. of Pa. Med. Bull., 

1906, v, 1. 
Norris, R. C. : " Ovarian Neoplasms Complicating Pregnancy and Labor." Am. Jour. Obst., 

1913, lxviii, 420. 
Outerbridge, G. W. : "Kruckenberg Tumor of Ovary." Am. Jour. Obst., 191 1, lxiv, 925; 

Ibid. : " Thyroid Tissue Tumors of Ovary." Am. Jour. Obst., 1913, lxviii, 1032. 
Pfannenstiel : " Die Histogenese der Dermoid und Teratome." Veit's Handbuch der 

Gynecology iii, 382, 1st Edition. 
Pick : " Struma Thyroidea Aberrata Ovarii." Deutsch. Med. Ztschr., 1902, No. 35 ; Ibid. : 

" Zur Kenntniss der Teratoma Blasenmoleartige Wucherung in einer ' Dermoid ' Cysts 

des Eierstocks." Berl. klin. Wchnschr., 1902, No. 52. 
Porter, M. F. : " Sarcoma of Ovary." Jour. Ind. Med. Asso., 1915, viii, 119. 
Reel, P. J. : " Diffuse Fibromyomata of Ovary." Am. Jour. Obst., 1917, lxxv, 400. 
Ries, E. : " Struma of Ovary." Surg., Gynec. and Obst., 1914, xviii, 262. 
Rosenow, E. C, and Davis, C. H. : " The Bacteriology and Experimental Production of 

Ovaritis." Jour. Am. Med. Asso., 1916, lxvi, 1175. 
Schlagenhaufer: " Ueber des Vorkommen Chorioepithelion und Traubenartiger Wuch- 
erung im Teratomen." Wein, klin. Wchnschr., 1902, Nos. 22 and 23. 
Stone, W. S. : "Metastatic Carcinoma of the Ovaries." Surg., Gynec. and Obst., 1916, 

xxii, 407. 
Vineberg, H. N. : "Twisted Ovarian Cyst Complicated with Pregnancy, Simulating Symp- 
toms of Renal Calculus." Am. Jour. Obst., 1914, lxx, 68. 
Wiener, S. : " A Study of the Complications of Ovarian Tumors." Amer. Jour. Obst., 1915, 

lxxii, 209. 
Wilder, R. M. : " Peritonitis Following Acute Ovaritis of Anginal Origin." Jour. Am Med 

Asso., 1916, lxvi, 569. 
Wilms : Die Mischgeschwiilste. Georgi, Berlin u. Leipzig. 



CHAPTER XXI 
PELVIC INFLAMMATORY DISEASE 

Classification Etiology, and Pathology. — Pelvic inflammatory disease is 
a term which may be used to denote lesions of an inflammatory type affect- 
ing the pelvic organs. Such lesions may be acute or chronic, and may in- 
volve, either singly or collectively, the uterus and adnexa (metritis, 
salpingitis, ovaritis) ; the pelvic peritoneum (peritonitis), and the pelvic 
cellular tissue (cellulitis, lymphangitis, parametritis). 

The exciting cause of pelvic inflammatory disease is bacterial infection ; in 
some forms, notably the puerperal, trauma may be a predisposing factor. 

It is convenient to classify acute pelvic inflammatory disease from the 
clinical standpoint as : 

First: Pelvic inflammatory disease occurring in the course of gonor- 
rhoea (gonorrheal) . 

Second: Pelvic inflammatory disease occurring after abortion or labor 
(post-abortal, post-partal). 

Third: Pelvic inflammatory disease, occurring after instrumentation or 
operation on the uterovaginal tract (post-operative). 

Fourth : Pelvic inflammatory disease occurring in the course of tuber- 
culosis (tuberculous). 

Fifth : Pelvic inflammatory disease occurring in the course of general 
infections (typlioid fever, small-pox, scarlet fever, etc.). 

A major proportion of pelvic inflammation is caused by the gonococcus. 
If gonorrhoea is not energetically treated and stamped out before it gains a 
foothold in the cervix it sooner or later reaches the adnexa. Just what pro- 
portion of inflammatory cases are due to the gonococcus it is difficult to 
determine, because the pus in old cases of pyosalpinx is very often sterile, 
and no organisms can be recognized either from smears or from cultures. 
Nevertheless, all investigations indicate the preponderating influence of the 
gonococcus. Miller examined bacteriolcgically 43 specimens of pyosalpinx, 
ovarian abscess, etc., which had been removed by laparotomy. Of these 33 
were negative ; in seven the gonococcus was found ; in one there was a mixed 
infection of the streptococcus and staphylococcus. Kronig in 122 cases of 
suppurative salpingitis or pyosalpinx found 75 negative ; the gonococcus was 
found in 28 cases ; the tubercle bacillus in eight ; the streptococcus in three ; 
the staphylococcus in one ; and in one case the bacillus coli communis. 

In post-abortal or post-partal disease, the streptococcus plays the most 
important role. Williams examined the uterine lochia in a series of 150 
cases of his own, in which the temperature rose to 101 F. or higher during 
the first ten days of the puerperium. He found the streptococcus in 31 ; 
the bacillus coli communis in 1 1 ; the gonococcus in seven ; the staphylococcus in 
four; mixed infection in 14; unidentified aerobic bacteria in four; unidentified 
anaerobic bacteria in eight; the bacillus of diphtheria in one, and the bacillus of 

411 



412 GYNECOLOGY 

typhoid fever in one; 25 of the cases exhibited no organisms whatever, while in 
45, although bacteria were found on the cover-slips, no growth occurred on any 
of the more usual culture media. It is evident from this and other studies that 
although the streptococcus is the organism that most frequently produces post- 
abortal or post-partal infection, the bacillus coli communis, gonococcus, 
staphylococcus, and certain saphrophytes play a considerable part. 

Pelvic inflammatory disease occurring after instrumentation or operations 
on the uterovaginal tract is very rare. Formerly, when the sounding of the 
uterus and intrauterine applications were common, infections of this sort 
were more frequently observed. At the present time the introduction of 
foreign bodies into the uterus for the purpose of bringing on the menstrual 
flow (delayed menstruation or early pregnancy) is the most common source 
of this clinical variety of infection. The organisms involved are the same 
as those observed in puerperal inflammation, notably the streptococcus, 
colon bacillus, and staphylococcus. Post-operative pelvic inflammation fol- 
lowing curettement or plastic operation on the uterovaginal tract is usually 
not an indication of a new infection, but rather the result of the outbreak 
and extension of an old one, especially of a previously existing but unrecog- 
nized gonorrhoeal salpingitis. 

Pelvic inflammatory disease secondary to tuberculosis elsewhere will be 
dealt with in Chapter XXX, page 560. 

Pelvic inflammatory disease occurring in the course of a general infection, 
from the deportation of the infecting organism through the blood-stream 
to the genital tract, has been observed especially in children with small-pox, 
typhus fever, scarlet fever, typhoid fever, etc. The inflammation, as a rule, 
is mild in type and unobserved, being masked by other symptoms. 

The course of a given case of pelvic inflammatory disease depends : Upon 
the nature and virulence of the infection; upon the condition of the genital 
organs, whether resting, pregnant, or puerperal, and whether or not the seat 
of injury, tears, bruises, etc., and finally upon the vital resistance of the 
woman. In other words, an infection due to gonorrhoea pursues a course 
different from that due to the streptococcus, and either of these infections is 
more serious during pregnancy or the puerperium than at any other time. 
An accidental streptococcus infection during an operation upon the utero- 
vaginal canal in the non-pregnant state does not give a clinical picture of the 
same degree of severity as a like infection following abortion, miscarriage, 
or labor. Gonorrhoea, when it extends to the adnexa during the puerperium, 
advances with Unusual rapidity. During pregnancy and the puerperal state, 
the genitalia provide a field most favorable to the growth of bacteria and the 
absorption of their toxic products ; and the anatomic changes in the lym- 
phatics and the blood-vessels favor the development of lymphangitis, phle- 
bitis, and septicaemia. 

GONORRHCEAL PELVIC INFLAMMATORY DISEASE 

Etiology and Pathology. — Gonorrhoeal infection usually travels by con- 
tinuity along the mucous membranes of the genital tract (Fig. 377). The 
gonococcus, once implanted in the tissues of the cervical canal, is afforded 
an opportunity to pass into the endometrial cavity by any circumstance 



PELVIC INFLAMMATORY DISEASE 



413 



which favors an exacerbation of the gonorrhceal inflammation ; dilates the 
internal os, the natural barrier between the cervix and the endometrium, or 
by any means which actually carries the infection into the uterus. The 
gonococcus may gain access to the uterus at the menstrual period, after 
labor, or during some intrauterine manipulation. After the endometrium 
has become infected, the disease is very apt to extend to the Fallopian tube, 
and thence to the pelvic peritoneum. Gonococcus salpingitis is the most 
frequent disease of the Fallopian tube (see Salpingitis, page 359). When the 
gonorrhceal pus escapes from the abdominal ostium, it irritates the pelvic peri- 
toneum and sets up a violent inflammatory reaction around the fimbriated 
extremity. This secondarily involves the ovary, which becomes covered 
with the inflammatory exudate. One tube is commonly affected before the 
other, but both tubes, as a rule, ultimatelv become involved. 




Fig. 377. — Diagram illustrating spread of gonorrhoeal infection, in contrast to streptococcus and 
staphylococcus infection (see Fig. 381). 



The inflammation of the peritoneum in a majority of cases remains con- 
fined to the pelvis, and under proper treatment shows little tendency to 
extend upwards into the general peritoneal cavity. This fact depends 
largely upon the anatomy of the parts and the peculiarities of the gono- 
coccus. The ovaries and the tubes lie in Douglas' pouch, between the broad 
ligaments and the rectum. The great omentum, small intestine, and the 
sigmoid flexure dip down into the pelvis and cover the viscera more or less 
completely. The gonococcus seems to be little disposed to extend rapidly 
along the peritoneal surfaces. The serous surfaces of any of the structures 
named, when they are inflamed, have a tendency to adhere to the other 
surfaces adjacent to them, and in this way the infected areas are quickly iso- 
lated and the spread of infection is checked. The lesions usually found in 



414 GYNECOLOGY 

the initial attack of gonorrhceal pelvic inflammatory disease are suppurative 
endosalpingitis, perioophoritis, and pelvic peritonitis. After repeated at- 
tacks, or as an ultimate result of the first one, there may be pyosalpinx and 
ovarian or. tubo-ovarian abscess. The pathology of these has been dis- 
cussed in Chapter XIX, page 359. 

Symptoms. — The symptoms of gonorrhceal pelvic inflammatory disease 
consist of sharp pain in the lower abdomen on one or both sides, associated 
with an elevation of the temperature, an increase of the pulse-rate, and 
tenderness and rigidity of the lower abdomen. These symptoms vary 
greatly, according to the virulence and extent of the infection. In the mild 
cases there may be very little variation of temperature or pulse, and the 
local manifestations may be very moderate, whereas in severe forms of 
infection all these symptoms are of the most extreme degree. 

An attack of gonorrhceal pelvic inflammatory disease usually begins dur- 
ing or shortly after the menses; the period often stops suddenly just before 
the attack begins. The history of a leucorrhceal discharge beginning soon 
after marriage or of suspicious intercourse may be elicited ; there may have 
been similar attacks before. The bowels are constipated, and abdominal 
distention, pain, rigidity, and tenderness are quite marked. Nausea and 
vomiting are commonly present, but the gastric symptoms are less promi- 
nent than the others. The temperature varies between 101 and 103 F., 
and the pulse is increased proportionately to 100 or 120; respiratory action 
is more frequent. A leucocytosis is invariably present, usually between 
10,000 and 15,000; rarely over 20,000. Chills are exceptional. The lower 
abdomen is tender and rigid, without much difference between the two 
sides. Evidences of a gonorrhceal infection may usually be found upon in- 
spection of the external genitalia or cervix (see Chapter XXIX, page 556). 

Bimanual pelvic examination, if the attack is the first one, will afford 
little definite information. The patient will complain of considerable ten- 
derness ; the lower part of the abdomen will be distended and rigid, so that 
deep palpation will be impossible; there will be considerable heat in the 
pelvis ; the vaginal fornices will be quite tender, and movement of the uterus 
will be painful, but in the acute stage, no pelvic masses are likely to be felt. 

Diagnosis. — It is very important at this stage to differentiate the attack from 
appendicitis ; both have fever, acceleration of pulse-rate, and pain and tenderness 
in the lower abdomen, and both are accompanied with leucocytosis. In 
gonorrhoeal pelvic inflammatory disease, however, the history of a Neis- 
serian infection may be obtained, or evidences of it may be discovered. The 
gastric symptoms are less pronounced, and yield more rapidly to treatment 
than in appendicitis. The pain does not affect the upper abdomen. The 
muscle spasm and rigidity are often noted on both sides of the lower abdo- 
men. The greatest tenderness is below the level of McBurney's point and 
more to the median line. There is less likely to have been preceding indis- 
cretion in diet. The temperature is relatively higher while the leucocytosis 
is relatively lower than in appendicitis. The symptoms of acute gonorrhoeal 
pelvic inflammatory disease tend to become progressively less if appro- 
priate treatment is instituted. This is not so frequently the case in appen- 
dicitis. Gonorrhoeal pelvic inflammatory disease must also be distinguished 



PELVIC INFLAMMATORY DISEASE 415 

clinically from puerperal pelvic inflammatory disease. The symptoms of the 
latter condition are often more general than local ; there is much more 
toxaemia and prostration in puerperal than in gonorrhoeal pelvic inflamma- 
tory disease. Fortunately, the history and the circumstances of the attack 
point to its true nature (post-partal, post-abortal, post-operative) (see 
page 419). 

Treatment. — The treatment of acute gonorrhoeal pelvic inflammatory 
disease is never surgical. There are certain cases in which the disease may 
so closely resemble an acute inflammation of the appendix that the surgeon 
will open the abdomen expecting to find appendicitis, but this is exceptional. 
If the diagnosis is clear, or, if the medical attendant leans toward the diag- 
nosis of salpingitis, and the patient shows no symptoms which demand an 
immediate exploratory celiotomy, non-operative measures should be insti- 
tuted as follows : The patient should be kept quiet in bed, in the Fowler 
position ; nothing should be allowed by mouth ; intestinal distention should 
be relieved with enemas ; continuous enteroclysis should be given, and ice- 
bags should be placed upon the lower abdomen. Laxatives and cathartics 
are contraindicated. It is rarely necessary to use stimulants or sedatives. 
The pain is relieved by cold applications to the abdomen. As soon as the 
acuteness of the attack has subsided, vaginal douches as hot as the patient 
can bear (ioo° F.) (see Vaginal Douches), should be started, using a solu- 
tion of bichloride of mercury (1 : 10,000) ; a considerable quantity (one to 
two gallons) of solution should be used. At the same time, the ice-pack 
should be replaced with hot compresses or hot flaxseed poultices. Under 
this plan, usually within three days, sometimes a week, the temperature and 
the pulse will be reduced to normal, the patient will no longer complain of 
pain, distention of the abdomen will be relieved, and there will be much less 
rigidity and tenderness. At this stage examination will show more or less 
fixation of the uterus, with adnexal masses on one or both sides. Usually 
it will be difficult to outline these masses on account of tenderness, and be- 
cause the adnexal tumor is accompanied with pelvic exudate and oedema of 
the broad ligaments. If the local treatment is continued, the exudate is 
absorbed gradually, the tenderness disappears, and the characteristic 
sausage-shaped (pyosalpinx and adherent ovary) adnexal tumor may be 
distinguished lying to either side of and behind the uterus. For a while 
energetic palpation of the mass will produce considerable pain, and possibly 
an exacerbation of the temperature and the pulse, but the longer the patient 
is kept under the therapeusis mentioned, the less marked will be the reaction. 

If it can be avoided, operation should never be undertaken until palpa- 
tion of the pelvis is comparatively painless, and there is no rise in tempera- 
ture or pulse-rate following a vigorous examination. Even then it is advis- 
able to continue the palliative treatment, hot douches, etc., until the pelvic 
masses no longer become smaller but remain stationary in size. The reason 
for delay in the operative treatment of acute salpingitis is because of the 
disadvantages of operation during the acute stage. A spread of infection to 
the peritoneal cavity is much more likely to -occur at this time than later ; 
the fresh exudate rnakes conservative surgery almost impossible, and the 



416 GYNECOLOGY 

tissues are so friable as to materially increase the technical difficulties of the 
operation. In the subacute or chronic stage, the danger from a spread of 
the infection is almost nil, for the organisms lose their virility or die; the 
precise extent of the injury to each individual organ can be determined; 
diseased portions can be removed and the healthy allowed to remain ; the 
plastic exudate has disappeared; the tissues have lost their friability, and 
the technical difficulties have been largely overcome. 

In some cases diagnosed as gonorrhceal pelvic inflammatory disease, not- 
withstanding the rest in bed and the palliative measures advised, the tem- 
perature will not fall to normal, but maintains a more or less continuous 
course, and this almost invariably indicates a mixed infection. When this 
happens the palliative treatment must be continued for a much longer time 
than usual. If a localization of pus occurs in Douglas' pouch, the abscess 
may be opened and drained through a posterior vaginal incision. If the 
pelvic masses are higher, operation should be deferred, as a rule, but when 
the symptoms continue and the general condition of the patient becomes 
progressively worse, a plan sometimes crowned with success is to make a 
posterior vaginal incision and endeavor to break into the abscess sac by a 
cautious separation of the inflamed surfaces by the examining finger, or, to 
make an exploratory abdominal incision, and, under the guidance which 
this affords, drain the infected area through the vagina, or if vaginal drain- 
age is impracticable, through the lower end of the celiotomy incision. It is 
wise always to avoid operation, if possible, while the septic elevation of 
temperature and pulse continue, unless the presence and situation of pus is 
evident and drainage may be quickly and safely instituted. 

The treatment of gonorrhceal pelvic inflammatory disease in the subacute 
or chronic stage depends upon the degree and extent of the pelvic condi- 
tion, upon the suffering which the patient has to endure, and upon her 
social state. In mild cases when the alteration of form is slight and the 
adnexal enlargement is small; when the uterus is in normal, or nearly 
normal, position ; when the patient is not incapacitated for work or play, 
and especially if she is in such circumstances that she can afford to take 
life easy and receive continuous treatment, palliative measures may be con- 
tinued with the hope of temporary, if not permanent, relief of the 
troublesome symptoms. 

When the adnexal masses are larger ; when there is displacement of the 
uterus; when there are symptoms which evidently result from adhesions 
between the pelvic and the neighboring structures, when the patient is 
obliged to earn her living and has little time to devote to hygienic meas- 
ures, and when the suffering is more or less constant and severe, then 
nothing but operation will suffice. A good test in doubtful cases is to allow 
the patient to resume her normal activities after all the acute symptoms 
have subsided during a more or less prolonged continuance in bed, and then, 
if she continues to suffer in any way, either at or between her menstrual 
periods, or both, operation is desirable. 

The nature of the radical abdominal operation for chronic gonorrhceal 
pelvic inflammatory disease depends upon the extent of the lesion and the 
pathological changes which have occurred in the pelvic organs. When the 



PELVIC INFLAMMATORY DISEASE 417 

operation has been postponed until all the acute symptoms have subsided, 
the surgeon is able to estimate the extent to which the pelvic organs have 
been damaged, and therefore is better able to judge what may be con- 
served and what must be totally removed. 

It is a good plan before opening the abdomen to thoroughly disinfect 
the external genitalia, burning out or excising infected glands, amputating 
or cauterizing infected cervical tissue, and thoroughly curetting and cauteriz- 
ing the endometrial cavity. All of this is not always feasible if the patient is 
in poor condition or if it is likely that it would prolong the operative pro- 
cedure beyond safe limits, but the curettement and cauterization of the cervix 
and fundus are of the greatest importance. It is only after the abdomen is 
opened that the surgeon will be able to determine positively the extent of the 
operation. It may be necessary to do a total extirpation of the uterus and ap- 
pendages, or the operator may stop with the removal of both tubes, leaving the 
ovaries, or it may be possible to save but one ovary or one tube. As a rule, if it is 




Fig. 378. — Bilateral pyosalpinx. Perioophoritis. (Gynecological Laboratory. U. of P.) 

found requisite to remove both ovaries and both tubes, the uterus itself 
should be taken out. 

When this must be done the first step in the operation consists in 
releasing the adhesions between the pelvic and the surrounding struc- 
tures, freeing the uterus and both tubes and ovaries, and inspecting the 
damage which has been caused to each of them. If a tube con- 
tains pus it should be removed without hesitation. If an ovary is covered 
with dense adhesions, or if it has undergone cystic degeneration so that the 
entire organ is made up of cystic spaces of varying size, unquestionably its 
removal is advisable. If the ovarian capsule is not much thickened and the 
cystic changes in the ovary itself are not pronounced, suspension of the 
ovary in a new position may be sufficient to effect a cure. If the tubes have 
been so adherent that, when released from adhesions, they show an almost 
uniformly raw surface with many bleeding points, removal is usually the 
best plan, and the same may be said of the ovaries. In some cases the 
process of releasing the adhesions which have formed between the adnexa 
and the surrounding parts will so mutilate the ovary or tube as to make 
27 



418 



GYNECOLOGY 




their removal imperative. If the ovary is considerably damaged and the sur- 
face bleeds freely, resection may be done if the other ovary is in question- 
able or bad condition (Fig. 379). When the tube is distended with clear 
fluid (hydrosalpinx), the outer part of the tube may be excised (Fig. 380), 
and the mucosa of the tubal canal united with the serous coat by fine sutures, 
with the hope that the possibility of conception and reproduction will be 
preserved. The number of instances in which this plan will be feasible are 
few, and it will almost invariably fail, unless : the occluded tube contains 
no infectious matter; the part of the tube which is left has a smooth outer 
surface and an intact lining mucosa, and the tube presents no obstruction to 
its lumen between the new ostium and the uterine cavity as evidenced by 

marked distortion, twists, or 

^_ -^ localized enlargements. 

As a rule, it is better either 
to remove the ovary in toto, or 
to let it remain undisturbed. 
In exceptional cases, it will be 
possible to leave a small por- 
tion of the hilus of a badly 
M diseased ovary, but the fre- 
quent practice of resection of 
one-third or one-half of the 
ovary, or the indiscriminate 
puncture of follicles, or cau- 
terization of infected areas, 
will result in subsequent 
trouble in a large proportion 
of cases. Furthermore, the 
surgeon must be guided by the 
condition of the other ovary. 
If that is entirely healthy, total 
removal of the affected organ 
is preferable to resection. It 
is quite common for the isth- 
II mus of the tubes to be enlarged 
and present nodular masses at 
the uterine cornua — salpingitis 
nodosa — but such conditions do not indicate the removal of the uterine fundus, 
since the diseased tube and the adjacent uterine cornua may be excised by a 
wedge-shaped incision. If the preliminary curettement and disinfection of the 
endometrium have been carried out, the excision of diseased cornua will leave 
the uterus potentially healthy and capable of the menstrual function. 

The whole attitude of the surgeon should be to preserve, if possible, the 
menstrual and the reproductive functions in young women. No surgical 
risks imperiling life should be taken to preserve the reproductive functions, 
unless it is the voluntarily expressed wish of the patient. If the patient | 
desires it, the chance may be taken of leaving a badly damaged tube or 




C\ 



/^=^=>, 




V 



SX 



Fig. 379. — Resection of the ovary. 



PELVIC INFLAMMATORY DISEASE 



419 




ovary in the hope of subsequent pregnancy, but otherwise the surgeon will 
do well to remove any such organs. 

Every effort should be made, however, to preserve the menstrual func- 
tion, for upon this much of the happiness of the individual depends, and the 
complete removal of the pelvic organs at an early age is often followed by 
nervous phenomena which are disastrous and permanent. There are numer- 
ous cases, however, in which it is utterly impossible to conserve even a 
vestige of either tube or ovary, and under such circumstances the surgeon 
should not hesitate, but pro- 
ceed to remove both adnexa 
with the fundus of the 
uterus (see Ovarian Trans- 
plantation, Chapter 
XXXIII). 

PUERPERAL PELVIC INFLAM- 
MATORY DISEASE 

Etiology and Pa- 
thology. — Pelvic inflamma- 
tory disease of this variety 
is due to the introduction 
of infectious material into 
the genital tract, usually 
into the uterus, after labor, 
miscarriage, or abortion. 
The organisms commonly 
involved are the strepto- 
coccus, the bacillus coli 
communis, and the staphy- 
lococcus ; the gonococcus 
and the saprophytic organ- 
isms, also, are occasionally 
found. In contradistinc- 
t i o n to the gonococcus. 
which travels along the 
mucous membranes of the 
genital tract, as a rule, and 
shows feeble powers of 
penetration, the streptococcus enters the uterine wall by inoculation at some 
point and, by means of the lymphatics or veins, passes directly through the wall 
of the uterus. Thus when the cervix or the lower uterine segment is infected 
by the streptococcus (Fig. 381), the infection extends through the uterine wall 
into the cellular tissue at the base of and between the layers of the broad liga- 
ments (cellulitis). When the infection is deposited at a higher point it may 
reach the ovary (ovarian abscess) through the lymphatics of the broad and 
the utero-ovarian ligaments. Ovarian abscess is the most common adnexal 
lesion in puerperal pelvic inflammatory disease. Again, the infection may pass 
through all the coats of the uterus and attack the peritoneum (pelvic peritonitis) 




Fig. 380. — Salpingostomy (page 438). 



420 



GYNECOLOGY 



or the adnexa (perisalpingitis-perioophoritis) ; or it may infect the thrombi and 
veins at the placental site (thrombophlebitis). Very often, not one, but several 
of these avenues are traversed by the infection, so that there may be various 
combinations of septic lesions. Puerperal pelvic peritonitis due to the strep- 
tococcus is much more apt to extend into the abdomen than gonococcus 
peritonitis. Infections of the mucosa of the tube, endosalpingitis and pyo- 
salpinx are quite unusual in puerperal pelvic inflammatory disease ; but a 
hydrosalpinx may be formed by inflammation of the outer serous coat of the 
tube with occlusion of the abdominal ostium. 

The progress of the infecting organisms may be stopped at any point by 
the resistance of the tissues. The symptoms resulting from the entrance of 
the toxins (toxaemia) of the bacteria themselves (bacteriaemia, septicaemia, 




Fig. 381. — Diagram, illustrating streptococcus and staphylococcus infections spreading through 
the veins and lymphatics. (See Fig. 377.) 



pyaemia) into the general circulation are often a prominent feature of 
puerperal pelvic inflammatory disease. Sometimes the toxins overwhelm 
the patient and death occurs before there are any demonstrable local evi- 
dences of infection. The pelvic lesions which may result from puerperal 
pelvic inflammatory disease are any one or any group of the following: 
Acute endometritis; acute metritis; uterine abscess; cellulitis; abscess of 
the cellular tissue ; ovaritis ; ovarian abscess ; peritonitis, localized, pelvic, or 
diffuse ; lymphangitis of the broad ligaments and pelvic lymphatics ; throm- 
bophlebitis of the veins at the placental site, and in the broad ligaments, etc. 
Symptoms. — The trouble dates from labor or abortion, or some intra- 
uterine manipulation or operation during pregnancy. The disease is either 
ushered in suddenly by a chill and by pyrexia of an alarming degree, some- 
times as high as 105 F., or the fever gradually develops during the first 
days or week of the puerperium. There is a leucocytosis of from 15,000 to 



PELVIC INFLAMMATORY DISEASE 421 

25,000, sometimes as much as 40,000. The pulse-rate is usually more rapid 
than would correspond to the height of the temperature. Indeed, the first 
symptom of puerperal infection may be an undue rapidity of the pulse. 
There may be actual chills associated with hyperpyrexia, or merely chilly 
sensations without any marked variation in the temperature curve. The 
patient may complain of pain in the lower abdomen, worse, perhaps, upon 
one side, though in many cases the pain is very slight. Constipation is the 
rule, although there may be diarrhoea later in the more septic cases. Head- 
ache is often present. The lochial discharge has no odor unless there are 
retained and putrefying secundines, and except in such cases the amount of 
the lochial discharge is diminished. 

Diagnosis. — Puerperal peritonitis follows labor, abortion, or some intra- 
uterine manipulation or operation during pregnancy. Careful inquiry as 
to the course and conduct of the labor or the abortion may indicate the 
probability of the direct introduction of infectious germs into the utero- 
vaginal tract. In cases of criminal abortion, the patient may often deliber- 
ately attempt to deceive the physician. The general symptoms are much 
more violent, as a rule, in the puerperal than in the gonorrhoeal form of 
peritonitis. The disease may manifest itself within a few hours or several 
days of the infection. There is often but little pain. The general symptoms 
of intoxication, however, such as pyrexia, rapidity of the pulse, etc., are 
always greater than in the gonorrhoeal form. 

Examination of the birth canal and the pelvic organs must be made with 
the utmost care and gentleness. In the earlier stages of puerperal pelvic 
inflammatory disease examination may show nothing ; local evidences of 
infection may not be present. As the disease progresses, unless the patient 
is overwhelmed and dies of the toxaemia, the local evidences develop. The 
external genitalia, perineum, vagina, and cervix should be inspected and 
carefully palpated for evidences of inflammatory and infectious processes 
(induration, tenderness, false membrane). The size of the uterus is usually 
greater than would normally correspond to the day of the puerperium 
(arrested involution) ; the cervix may be patulous (arrested involution or 
retained secundines). The uterus may be fixed with areas of induration on 
one or both sides (cellulitis, adnexitis, pelvic peritonitis). The uterus may 
be displaced by a mass on one side or back of it (ovarian abscess). The 
lower abdomen may be tender and rigid (metritis, adnexitis, peritonitis) ; 
the uterus may be very distinctly enlarged and palpable (subinvolution, 
metritis) ; the abdomen may be distended ; peristalsis may be diminished or 
absent (peritonitis) ; there may be an area of tenderness over Poupart's liga- 
ment at the femoral sheath, or along the femoral vein ; there may be oedema 
of the corresponding leg (femoral thrombophlebitis). 

Prognosis. — The outcome of the attack is always doubtful. A rapid 
absorption of toxic products from the infected pelvic organs or from a 
spreading peritonitis may quickly end in death. Except in the most virulent 
forms of infection and those associated with perforation or rupture of the 
uterus, or in neglected or badly treated cases, the outlook is more hopeful. 
The prognosis is of necessity dependent to a considerable degree upon the 
virulence of the infecting organism and upon the strength of the patient. An 



422 GYNECOLOGY 

estimation of the white blood corpuscles may be of some value as an indica- 
tion of the patient's resistance to the infection. A comparatively high leuco- 
cytosis is favorable. A low count in the presence of severe general symp- 
toms is bad. The worst cases are those in which the general symptoms are 
marked and yet the localized evidences are slow in appearing, or do not 
appear at all. The patient under such circumstances suffers from the pres- 
ence in the blood of the infectious organism and its products — bacterisemia. 
If the toxin alone is present, the prognosis is less serious. Blood cultures 
should be made, if possible, in every suspected case. If the streptococcus is 
found, the outlook is dubious ; the staphylococcus and the bacillus coli 
communis are less dangerous, although bacteriaemia of any variety is often 
fatal. When the infection becomes localized in the pelvis, as is evidenced 
by the development of pelvic masses (ovarian abscess, pelvic peritonitis), or 
areas of stony hardness (cellulitis), the prognosis is better. If pus forms 
in an easily accessible position (ovarian abscess in Douglas' pouch ; abscess 
in the cellular tissue of the broad ligament), vaginal puncture and drainage 
will usually result in immediate improvement in the general condition, and 
may be followed by a speedy resolution of all the surrounding inflammatory 
changes in the pelvic organs. 

While in puerperal thrombophlebitis there may be nothing abnormally 
palpable in the pelvis at any time ; as a rule, some time during the course of 
the inflammation there will develop tenderness in the lower abdomen, broad 
ligament, inguinal and femoral region of the affected side, with more or less 
marked oedema of the corresponding lower extremity. There may be re- 
peated chills and alarming elevation of temperature without bacteriaemia. 
When there are no bacteria in the blood-stream the general condition re- 
mains fair in most cases, and while recovery is protracted, it finally occurs. 

End-results. — Puerperal pelvic inflammatory disease leaves little re- 
siduum in the way of structural changes. Infiltrates and exudates which do 
not progress to the formation of pus are gradually absorbed. If pus forms 
and is not evacuated by surgical means it gradually burrows its way until 
the abscess ruptures into the vagina, rectum, bladder, small intestine, or 
" points " externally above Poupart's ligament. The pelvic organs may 
return entirely to the normal, after the subsidence of the inflammation, even 
though extensive pelvic exudates have been present during the acute attacks. 
Adhesions between neighboring organs may become entirely absorbed, so 
that months or years afterwards a pelvic examination does not show the 
slightest evidence of the previous affection. For this and other reasons 
which will be shown later, the removal of organs for the cure of puerperal 
infection is seldom indicated. 

Treatment. — Puerperal pelvic inflammatory disease is a wound infec- 
tion. By the time the clinical evidences make their appearance the tissues 
have already been invaded by bacteria. Surgery can do nothing at this 
time, except in a few instances provide external drainage of the infected 
area ; it cannot cope with the infectious germs embedded in the tissues. 
The resistance of the patient must be the main reliance, and that can be 
lowered by injudicious or meddlesome treatment or increased by careful 
nursing and non-operative measures w T hich help to check the spread of the 



PELVIC INFLAMMATORY DISEASE 423 

disease. If there are indications of trouble in a perineal or a cervical tear 
which has been repaired, the sutures should be removed at once and the 
wound freely drained, so that there may be a minimum amount of absorp- 
tion from the infected surfaces. When the testimony of the medical at- 
tendant is clear that the entire foetus and placenta have been removed from 
the uterus, nothing should be done to disturb the interior of the uterus. Any 
intrauterine manipulation may do much harm by breaking down the pro- 
tecting layer of leucocytes, which may have formed beneath the endometrium, 
and thus opening up new channels of invasion. In some cases the testi- 
mony of the attendant is doubtful and it is impossible to say whether or not 
there is necrotic material within the uterus, in which infectious organisms 
are swarming and from which toxins are being absorbed. Under such cir- 
cumstances, if the os is unduly patulous, if the lochial discharge is free and 
of a putrid odor, if there are no indications of cellulitis or pelvic peritonitis, 
and if the pulse and temperature elevation are not excessive, the uterus may 
be gently explored with the finger and portions of placenta w r ithin easy 
reach removed with blunt placental forceps ; following this the lower uterine 
ligament and cervix may be packed with gauze. The gauze pack promotes 
further dilatation of the cervix, and separation and expulsion of remain- 
ing fragments of placenta. The pack is removed at the end of twenty-four 
hours, when gentle exploration of the uterine interior may be repeated 
unless one can be quite sure that the remainder of the placental tissue has 
been expelled. If the uterus is fixed and surrounded by areas of induration 
in the pelvis, if there is any evidence of peritonitis, if the temperature and 
pulse are high, and the general condition bad, the uterine interior should be 
let alone. An exception to this latter statement is found in those cases 
accompanied with profuse hemorrhage ; in them the uterus should be packed 
with gauze. All of these manipulations must be done with the most rigid 
aseptic technic. General anaesthesia may be required, but should be avoided 
if possible. The use of an operating table, support of the legs by stirrups, 
good light, and plenty of assistance facilitate the manipulations and often 
render the use of general anaesthesia unnecessary. Intrauterine douching 
and curetting are meddlesome and dangerous. Both have been the cause of 
immeasurable harm. No intrauterine antisepsis can do any good and 
curetting only serves to drive an infection deeper into the uterus than it 
was before. The patient should be placed in the Fowler position to favor a 
localization of the inflammatory process to the pelvis. Ice-bags should be 
placed upon the lower abdomen. The bowels should be moved daily with 
an enema, simple or compound, but no cathartics should be administered. 
Eight ounces of normal salt solution or two per cent, soda bicarbonate solu- 
tion should be infused slowly into the rectum every three hours. Nothing 
but liquids in small quantities should be permitted by the mouth. Ergotin 
(Bonjean) in dose of two or three grains every three hours may be pre- 
scribed with advantage, as it induces firm contraction of the uterus, favors 
the expulsion of placental fragments, and hinders absorption by diminish- 
ing the caliber of the veins and lymphatics in the uterine wall. After a 
few days, when the danger of a spreading peritonitis has passed, the amount of 
nourishment given may be increased, and a concentrated and nutritious diet 



424 GYNECOLOGY 

given. Milk, broths, koumyss, eggs beaten up with milk or broths, pre- 
digested beef, or any of the highly concentrated, nourishing forms of food 
should be given up to the point of toleration. The exhibition of drugs by 
the mouth should be limited, so that the stomach can be kept in good condi- 
tion for the digestion of food. Stimulants should be withheld until needed 
and then given in small dose, and gradually increased if more is required. 
Strychnia sulphate and alcohol in some form (whiskey, brandy, and cham- 
pagne) are the most useful. Digitalis, caffeine, and camphor may be held 
in reserve. The temperature, if excessive, can be controlled by the use of 
the cold sponge. If the patient complains of headache, an ice-cap should 
be applied. 

Many different antiseptic solutions have been recommended and used in 
the intravenous treatment of puerperal bacteriaemia, but none have survived 
the test of clinical experience. Of late, intravenous injections of arseno- 
benzol have been tried by Miller and Chalfant 1 in eleven cases. 

The use of sera — anti-streptococcus, anti-staphylococcus, and anti-colon 
bacillus — is still on trial ; on the whole, the results have been disappointing. 
Nevertheless, in all cases a blood culture should be taken and, if the strep- 
tococcus, colon bacillus, or staphylococcus is recovered, the corresponding 
serum or combination of sera should be injected. 

It appears from the observations of Hare, Davis, and others that the 
benefit sometimes derived from the use of these sera comes more from the 
foreign protein substance which they contain than from any specific anti- 
toxic effect. Horse serum is said to do as much good as a serum prepared 
from the specific organism. 

Vaccines have been used to hasten the resolution and absorption of pelvic 
exudates in the subacute stage of puerperal infection. An autogenous 

1 There were seven recoveries and four deaths. In seven cases the blood showed 
the presence of various strains of streptococcus. Two of these cases died. In two* cases 
there was a Gramnegative bacillus with two recoveries. Two cases are included in the 
series who had a negative culture, but they were included as they were clinically blood- 
stream infections, and both proved fatal. Ten of the infections followed delivery at term 
and one self -induced abortion at three months. As a result of their observations, they 
concluded as follows : (i) " With the use of intravenous injections of arseno-benzol we have 
been able in every instance to rid the blood-stream of its invading organism; (2) all 
varieties of organisms we have so far encountered seem to be equally influenced; (3) cul- 
tures from localized abscesses are usually identical with cultures from the blood-stream. 
Cultures from the uterus, although this same organism is predominant, are rarely pure 
cultures ; (4) reinfections from focal infections may and do occur, but are not so readily 
influenced by the arseno-benzol as the original infections; (5) the leucocyte count is 
usually low in comparison with the temperature and pulse. After arseno-benzol has been 
given there is a marked increase in the count. If after this time there is a decided de- 
crease in the leucocyte count without a corresponding improvement in the patient, it is 
probable that the patient has reinfected herself and arseno-benzol may be given without 
waiting for confirmation of this by laboratory report; (6) in the cases we have had the 
blood-stream is usually found to be sterile in twenty-four hours, always in forty-eight 
hours; (7) rabbit experiments made by Dr. C. S. Allison, of the Singer Memorial Lab- 
oratory, would indicate that a dose of 6 decigrams is necessary to secure prompt results ; 
(8) in suspected blood-stream infections arseno-benzol may be given immediately after a 
culture has been taken in order to avoid the delay incident upon waiting for a lab- 
oratory report." 

In the discussion of this paper, Hare denied that the arseno-benzol could have any 
antiseptic destructive action upon germs in the blood-stream. He said that Ehrlich had 
admitted that " neosalvarsan and salvarsan had no specific direct effect upon the spirochseta 






PELVIC INFLAMMATORY DISEASE 425 

vaccine may be prepared from intra-uterine culture or stock vaccines of mixed 
streptococcus, staphylococcus, and colon bacillus may be used (see 
Chapter XLI). 

These questions at the present time are still in abeyance. In animal 
experimentation the results with bacterial vaccine and serum treatment are 
so remarkable that there is little doubt that some day this will be the solu- 
tion of the problem, but at the present time we know so little about it 
that no definite rules of practice can be formulated. 

Operation in puerperal pelvic inflammatory disease should be limited to 
the uterine exploration already described during the acute stage and to the 
evacuation of collections of pus which become manifest at a later date. 
When in the course of puerperal pelvic inflammatory disease a mass forms 
on one side of or behind the uterus which softens or " points " in Douglas' 
pouch, and the daily marked remissions of temperature and the leucocyte 
count indicate an abscess, posterior vaginal incision and drainage should 
be made. Likewise collections of pus in the cellular tissue of the broad liga- 
ments which " point " upon the surface of the lower abdomen above Pou- 
part's ligament should be evacuated. Otherwise the pelvis should be let 
alone ; after the temperature has returned to normal or nearly so and the 
disease is plainly under control, when the uterus is still enlarged (subin- 
volution), or there are masses on either side or back of it (cellular, adnexal, 
or peritoneal exudates), resolution may be hastened by hot douches. Opera- 
tion to correct permanent residua of inflammation, subinvolution, retroposi- 
tion, adherent or enlarged adnexa is not often required ; if so, it should be 
postponed as long as practicable, weeks or months, after all of the acute 
symptoms have subsided. 

INSTRUMENTAL OR POST-OPERATIVE PELVIC INFLAMMATORY DISEASE 

Etiology and Pathology. — Pelvic inflammatory disease may follow intra- 
uterine manipulation and operation on the uterovaginal canal. It results 
from the direct introduction of infectious organisms or from the spread of 
an infection already present. Infection may be directly introduced in the 
course of a plastic operation upon the vagina or the cervix, or during curet- 

of syphilis." He pointed out that if you " put neosalvarsan in a test-tube with spirochseta, 
the spirochseta is not destroyed by the salvarsan. If, however, you add to the test-tube 
blood serum, which acts as a complemental body, the spirochseta is at once destroyed by 
the salvarsan " ; that is, he showed that there was no germicidal action by the salvarsan 
" per se, but complementary or other bodies are produced which in turn destroy the parasite. 
If we accept this drug as having a specific influence upon bacteria which belong to another 
class than the protozoa or the parasites of syphilis, or' of sleeping-sickness, we have to 
believe that Ehrlich thought he had found a remedy for only one thing when he really dis- 
covered a remedy for many things. There is no evidence to date to indicate in any way what- 
ever in experimental pharmacology that salvarsan or neosalvarsan destroys bacteria 
belonging to the vegetable kingdom in contradistinction to the spirochseta which belongs 
to the animal kingdom. 

" The whole question of the specificity of salvarsan in respect to syphilis has particular 
relationship to the problem placed before us. It seems that an interesting series of experi- 
ments might well be made by taking the microorganisms derived by culture from the 
affected blood and putting them in test-tubes with salvarsan or neosalvarsan in the presence 
of, and without the presence of, blood-serum and determining whether under such circum- 
stances salvarsan and neosalvarsan would have any germicidal effect upon these vegetable 
parasites in the same way that it has an effect upon the spirochseta." 



426 



GYNECOLOGY 



tage. Such an accident, however, is very rare in the hands of an operator 
who employs care in his technic. The use of soiled instruments in the 
course of an examination, or the passage of a sound into the uterus, with- 
out the thorough scrubbing and disinfection of the vagina and the cervix 
which should always precede it, has been a fertile source of infection in the 
past. At the present day no competent and intelligent physician would be 
guilty of such an error. Attempts to produce abortion by the unskilled or 

the uncleanly are very often 
v J followed by septic infection 

and sometimes by perfora- 
tion of the uterine wall. 
There are some instances, 
also, in which infection has 
occurred from the introduc- 
tion of a foreign body into 
the uterus with the purpose 
of producing abortion when 
pregnancy did not exist. 
Infections of this sort are 
produced by the strepto- 
coccus, staphylococcus, and 
colon bacillus. Pelvic 
inflammatory disease fol- 
lowing an aseptic operation 
is usually the result of the 
extension of an inflamma- 
tion which previously 
existed, but was not recog- 
nized at thev time, of the 
operation. Such infection 
is usually of a gonococcus 
type, and may have been 
localized in the endome- 
trium, in the tubes, or in 
the ovaries. While it is 
sometimes very difficult to 
detect an inflammatory proc- 
ess of this sort, the possi- 
bility of its existence should 
always be kept in mind, and 
every curettement or plastic operation on the uterus should be preceded by a 
careful pelvic examination. In case pelvic inflammatory lesions are recognized, 
the manipulations must be practised with as little disturbance as possible ; and 
in the majority of cases it will be advisable to open the abdomen directly after- 
wards and correct the diseased condition. 

Symptoms. — The symptoms depend upon the nature of the infection. 
If it is gonorrhceal and has resulted from an extension of the disease to the 
tubes or to the pelvic peritoneum, the symptoms will be those of gonorrhceal 




r^^vXoxvaNiwwv 



^ IG - 382. — Vaginal incision and drainage. First step. The posterior 

lip of the cervix is held forward. A transverse incision is made through 

the posterior vaginal wall exposing the peritoneum which is pushed 

out of the way. 



PELVIC INFLAMMATORY DISEASE 



427 



salpingitis or peritonitis. If the trouble results from the introduction of 
septic organisms during an operation, or during the passage of soiled instru- 
ments or of foreign bodies into the uterus, the symptoms will develop soon 
after the operation or instrumentation, and will resemble those of puerperal 
infection (see also Perforation of the Uterus, page 287). 

Treatment. — If there is good reason to believe that the symptoms depend 




Fig. 383. — Vaginal incision and drainage. The abscess is located by bimanual palpation and the end 

of a sharp-pointed curved scissors is guided upon the examining finger to the most dependent point of 

softening and fluctuation. The scissors are then thrust in and the pus evacuated. Separation of the 

points of the scissors as they are withdrawn enlarges the drainage opening. 



upon the extension of a gonorrhceal infection to the pelvic peritoneum, the 
palliative and conservative measures described under the treatment of 
gonorrhceal pelvic inflammatory disease are advisable. When the symp- 
toms appear to have followed the introduction of microorganisms during a 
plastic operation, the operative field should be exposed, the sutures removed 
if there is any evidence of infection, and drainage provided. Aside from the 
provision of drainage for the operative field, an expectant policy should be 



428 GYNECOLOGY 

adopted. The patient should be kept in the Fowler position in bed; the 
bowels should be opened daily ; a light nutritious diet should be given, and 
stimulants should be prescribed if necessary. Infection following attempts 
by the unskilled or the uncleanly to produce abortion is most dangerous. 
If, at the same time, the uterus is perforated the outlook is bad. The 
symptoms, prognosis, and treatment are the same as in puerperal infection. 

Pelvic Abscess. — A pelvic abscess, as the term is generally employed, 
signifies a collection of pus somewhere within the true pelvis, presenting a 
well-defined outline recognizable upon physical examination and giving 
rise to characteristic symptoms (intermittent fever, leucocytosis, etc.). A 
pelvic abscess may be a periappendicular collection of pus ; a large pyosal- 
pinx ; an ovarian abscess ; an intraperitoneal collection of pus surrounding a 
primarily infected ovary or tube, or a collection of pus in the cellular tissue 
of the broad ligaments. The most frequent cause of pelvic abscess is post- 
abortal, post-partal, and post-operative infection. The most frequent loca- 
tion is the ovary. 

The symptoms of pelvic abscess are those of acute pelvic inflammatory 
disease in which, notwithstanding the lapse of time and appropriate treat- 
ment (pages 416 and 420), the fever remains high and becomes remittent, leuco- 
cytosis increases, and a well-defined fluctuant mass forms in the pelvis. 

Treatment. — If the abscess occupies the pouch of Douglas and produces 
bulging of the posterior vaginal fornix, it should be evacuated by a pos- 
terior vaginal incision (Figs. 382 and 383). If the abscess is the result 
of a suppurative cellulitis and is extraperitoneal— within the layers 
of the broad ligament (see differential diagnosis, cellulitis and adnexal 
disease), operation should be delayed until the abscess points upon the 
lower surface of the abdominal wall above Poupart's ligament. If this does 
not tend to occur and there is no indication of a regression of the inflamma- 
tory trouble, the pus may be evacuated by means of posterior vaginal in- 
cision. Pelvic abscess high up which in spite of prolonged treatment 
does not point in an accessible location is unusual. When it occurs, 
a median abdominal incision may be made in order to accurately 
locate the exact situation of the trouble, and then through an extraperi- 
toneal incision in the lower abdominal region, parallel to Poupart's ligament, 
the abscess cavity may be drained without contamination of the peritoneum. 

CHRONIC PELVIC INFLAMMATORY DISEASE 

Etiology and Pathology. — Chronic pelvic inflammatory disease is a 
term used to designate the residuum of a previous acute pelvic inflammation. 
Such a residuum occurs much more frequently after gonorrhceal than after 
the post-abortal, puerperal, or instrumental forms of inflammatory disease. 
Gonorrhceal pelvic inflammatory disease in the chronic stage exhibits such 
pelvic lesions as endosalpingitis, pyosalpinx, or hydrosalpinx, perioophoritis, 
tubo-ovarian abscess or tubo-ovarian cyst, cystic degeneration of the ovary, 
simple retention cyst (corpus luteum or Graafian follicle cyst), and 
peritoneal adhesions. 

Puerperal or post-abortal inflammatory disease is less likelv to leave a 



PELVIC INFLAMMATORY DISEASE 429 

permanent defect in the pelvic organs. In favorable cases the infecting 
organisms are overwhelmed by the resistance of the patient ; the structural 
changes are few and rapidly subside. In the severer forms there may be 
certain residua, which result from an actual destruction of tissue during 
the acute process. Puerperal pelvic inflammatory disease in the chronic 
form may exhibit such lesions as subinvolution of the uterus, chronic 
metritis, atrophy of the uterus, perisalpingitis, hydrosalpinx, chronic 
oophoritis, ovarian abscess (sterile disintegrated pus), cystic ovary (cystic 
generation of a Graafian follicle or corpus luteum), and sclerotic ovary. 
For a more detailed description of the morbid anatomy of chronic pelvic 
inflammatory disease, see Chapters XIX and XX. 

Symptoms. — The symptoms of chronic pelvic peritonitis arise from me- 
chanical interference with the function of the pelvic organs produced by 
structural lesions and by recurrences of inflammation in the pelvic organs, 
arising from either new or latent infection. Dysmenorrhcea is a frequent 
symptom ; the pain begins before the flow appears and lasts until near the 
end of the period. There is congestion of the ovary and interference with 
rupture of distended follicles. The periods may be irregular, with a ten- 
dency to increased frequency and menorrhagia. Subinvolution — chronic 
metritis — may be present. When most of the follicle-bearing area of both 
ovaries has been destroyed, or in the rare cases of uterine atrophy, the inter- 
menstrual time may be lengthened and the flow scant. Leucorrhoea is a very 
common symptom ; the discharge may come from the cervix (chronic gonorrhoea 
— thick muco-pus) or from the endometrium (glandular hypertrophy — 
thin mucus). 

There is pain in the lower abdomen on one or both sides — worse at the 
menses, increased by exertion and constipation, and not relieved by the 
recumbent position. Vesical irritability is a common complaint — either 
frequency of urination or pain during or after the act. The bowels are 
usually constipated, and the patient complains of gaseous distention of the 
bowels, flatulence, etc. Pain during defecation, and dyspareunia are not 
uncommon symptoms, especially if the ovary is diseased and lies in Douglas' 
pouch in close proximity to the rectum or the vaginal fornix. Added to 
these chronic complaints, from time to time, especially in the gonorrhceal 
pelvic inflammatory cases, there may be an acute exacerbation of symp- 
toms. This results : from trauma, which releases some of the encapsulated 
bacteria or their toxins ; from the accumulation of faeces or gas above a point 
of constriction in the intestinal coils adherent to the pelvic structures, or to 
a new or fresh infection of the pelvic organs. Sterility is common in chronic 
pelvic inflammatory disease. 

Diagnosis. — The diagnosis of chronic pelvic inflammatory disease is 
made from the history of previous acute attacks, the symptoms, and the 
findings upon bimanual pelvic examination. The uterus is more or less 
fixed in a normal, retroverted, lateral, or descended position ; it may be 
slightly increased in size. The adnexa are enlarged, tender, and restricted 
in mobility. The elongated retort shape of a pyosalpinx or hydrosalpinx 
may often be distinguished from the spherical or elliptical shape of an 
affected ovary. When the lesion consists principally of adhesions and there 



430 GYNECOLOGY 

is but slight enlargement of the tube or ovary there may be little recog- 
nizable abnormality in the adnexa by palpation, except a feeling of restricted 
mobility. A thin-walled, flaccid hydrosalpinx may escape observation entirely. 
Treatment. — The treatment of chronic pelvic inflammatory disease may 
be non-operative or operative. The former plan may be adopted when the 
lesion is moderate in degree and the suffering of the patient not excessive ; 
this plan relieves the patient's sufferings, or at least renders them endur- 
able. The measures which have been found serviceable are those which 
prevent pelvic congestion, favor the absorption of inflammatory products, 
and reduce traumatism to a minimum. The bowels should be kept freely 
open so as to prevent accumulation of faeces or gas; hot saline douches (i 
to 2 gallons) should be taken, according to the requirements of the case, 
from several times a day to that often in a week. Hot sitz baths, the 
electric hip bath, and the general cabinet bath may be useful. Sexual inter- 
course must be restricted ; graduated exercise, walking, etc., without violent 
exertion, is beneficial. If these things do not relieve the patient sufficiently, 
or if the woman has been made sterile by the disease, operation may be 
undertaken. Adhesions may be released, diseased organs removed or par- 
tially resected, and the uterus may be placed in good position. (For a 
detailed discussion of the treatment of the tube or ovary see page 417.) 

CELLULITIS 

Etiology and Pathology. — Cellulitis is usually the result of post-partal 
or post-abortal infection. It may be produced by intrauterine instru- 
mentation or operation, and may also result from infected wounds following 
vaginal or perineal operations. 

When the disease is associated with labor or abortion, very often there 
are lacerations of the cervix which extend more or less deeply into the 
cervical tissues, or entirely through them, and into the parametrium. The 
infectious organism gains access to the cellular tissue by way of the lym- 
phatics or the veins. Primarily, the disease is either a lymphangitis or a 
thrombophlebitis ; secondarily, all the constituents of the cellular tissue are 
involved in the inflammation. 

Early in the disease there is an infiltration of the parts with small round 
cells and polymorphonuclear leucocytes. This inflammatory infiltrate gives 
a stony hardness to the tissues and fixes the pelvic organs. The induration 
usually extends from the uterus to the pelvic walls and fuses with the 
fascia and the muscles overlying the bony pelvis. It is often unilateral, 
affecting the broad ligament on one side only, though it may be found on 
both sides. When unilateral it may involve the uterosacral ligament on the 
affected side posteriorly (the paraproctium) , and the uterovesical liga- 
ment on the same side anteriorly (the paracystium). The paracolpium 
especially is invaded when the trouble starts from an infected wound of the 
vagina or the perineum. The areas involved in the process depend upon 
the course of the lymph vessels or veins draining the infected w r ound. 
Cellulitis may be combined with peritonitis. When this happens the two 
conditions may be coincident, though more commonly the peritonitis is 



PELVIC INFLAMMATORY DISESAE 431 

secondary to the cellulitis, and results from a direct extension of the inflam- 
mation from the cellular tissue to the pelvic peritoneum. 

The inflammatory process either undergoes resolution with absorption 
of the exudate or it softens and forms an abscess. The pus, as a rule, bur- 
rows along the wall of the vagina, causing the vaginal fornix to bulge, 
and if not released by incision, it bursts into the vagina or into the rectum. 
The pus may also be discharged into the bladder, or rarely into an adherent 
loop of intestine. Or, the abscess being extraperitoneal, the pus may lift up 
the peritoneum, reflected from the anterior surface of the broad ligament to 
the anterior abdominal wall, and make its appearance in the groin above 
Poupart's ligament. Rarely it may pass behind the posterior layer of the 
pelvic peritoneum to the mesosigmoid and present itself externally in the 
loin. Cases are on record where the pus has burrowed through the pelvic 
fascia from the paracolpium and the paraproctium to the ischiorectal fossa. 
When such collections of pus are discharged spontaneously, the abscess 
cavity rapidly closes and the patient usually makes a prompt recovery. 

Symptoms. — The subjective symptoms of cellulitis are similar to those 
of acute pelvic inflammatory disease following abortion, labor, or septic 
instrumentation. If suppuration occurs, the temperature assumes a hectic 
type unless prompt incision is practised. When the paraproctium is in- 
volved, rectal irritability may be a prominent feature ; when the paracystium 
is involved, there is usually frequent and painful urination. 

The objective signs are somewhat different from those of pelvic peri- 
tonitis with salpingitis and ovaritis, unless accompanying the latter there 
is a considerable amount of plastic exudate ; the differential diagnosis then 
may be nearly or quite impossible. As a rule, upon bimanual palpation, the 
vault of the vagina, on one or both sides, or entirely around the cervix, is 
densely hard. The mucosa feels as if it closely overlaid tissues carved out 
of wood. The cervix is fixed as if frozen into an area of dense induration, 
which extends without interruption to the bony pelvic wall. If both broad 
ligaments are involved the uterus may be absolutely immobile. 

Examination per rectum will show the same dense hardness of the pelvic 
mass. If the exudate involves the paraproctium at the point where the 
uterosacral ligaments surround the rectum, the lumen of the bowel will be 
narrowed, and to the palpating finger at this point it will feel like an auger- 
hole in a board, covered with the rectal mucosa. If suppuration occurs, the 
parts lose their stony hardness, and fluctuation becomes manifest within 
several days. W T hen the abscess is small and does not bulge into the 
vagina, it may be difficult to detect fluctuation. In such cases the tissues 
of the vaginal vault may feel cedematous and there may be slight pitting 
upon pressure. Quite frequently the abscess points at one side of the 
vaginal vault. 

Diagnosis. — The mass in pelvic cellulitis, as contrasted with that in 
pelvic peritonitis with salpingitis and ovaritis, is more apt to extend con- 
tinuously from the cervix to the pelvic wall and to be firmly fixed to the bony 
pelvis. In peritonitis the mass can often be recognized, occupying a posi- 
tion posterior to the broad ligament. When there is much exudate asso- 
ciated with pelvic peritonitis, the differential diagnosis is more difficult or 



432 GYNECOLOGY 

impossible. In such cases the pelvic mass is apt to fill up Douglas' pouch 
and press the anterior rectal wall backward, instead of surrounding it as it 
does in cellulitis. 

Treatment. — The general treatment of septic or of puerperal cellulitis 
differs but little from that of puerperal pelvic inflammatory disease. Under 
the influence of rest in the Fowler position, liquid diet, daily enemas, cold 
to the hypogastrium and later heat to the abdomen, and hot vaginal douches, 
a considerable percentage of cases of pelvic cellulitis undergo resolution and 
spontaneous recovery. 

At times exudates filling half the pelvis disappear. When pus forms 
it should be evacuated promptly as soon as an area of pointing or softening 
can be detected ; an incision sometimes hastens absorption in the case of 
large exudates even though suppuration has not occurred. Whenever pos- 
sible, the broad ligament should be opened from the vagina, the folds of the 
broad ligament being separated with the fingers, when necessary, in order 
to reach deep-seated abscesses. At times the incision must be made in the 
inguinal or the lumbar region. 

Chronic Pelvic Cellulitis. — Chronic cellulitis occasionally occurs as the 
sequel of an acute attack. In some of these cases there is an actual chronic 
inflammation of the cellular tissue and by a painstaking microscopic ex- 
amination areas which show inflammatory infiltration may be found. In 
other cases the inflammatory process has ceased, but a residuum of hyper- 
plastic or cicatricial tissue is left in the cellular tissues. It is often impos- 
sible to distinguish clinically between these two forms. According to 111, 
cellulitis may also be chronic from the beginning. Thus ulceration of the 
bladder and dysenteric and follicular ulceration of the rectum may produce 
a localized low-grade inflammation of the neighboring cellular tissue which 
finally results in a contracting cicatrix and atrophy of the cellular tissue. It 
should be remembered that normally the pelvic connective tissue varies in 
different individuals, and that the rectum and the uterosacral folds in many 
women are sensitive to pressure through the vaginal vault. The con- 
clusion, therefore, that an actual lesion of the cellular tissue is present be- 
cause the uterosacral ligaments feel thicker than normal or are tender 
on pressure, is not justifiable. 

Symptoms. — The patient complains of the usual train of gynecologic 
symptoms — backache, dysmenorrhcea, leucorrhcea, etc., depending in the 
individual case upon the part of the cellular tissue affected and the amount 
of dislocation of the pelvic organs which has been produced. 

Diagnosis. — Scars in the vaginal vault extending from the cervix may 
be readily felt upon palpation. Contraction of the cellular tissue elsewhere 
is harder to distinguish positively from intraperitoneal adhesions. Need- 
less to say, a positive diagnosis is sometimes impossible. 

Treatment.— The purpose of treatment is to absorb the cellular exudate 
and to stretch cicatricial bands. To secure absorption a daily vaginal 
douche of hot normal saline solution should be ordered, followed by rest in 
the recumbent posture for at least an hour, saline laxatives, and the use of 
tampons. The tampons soaked in glycerite of boroglycerine should be 
introduced three times a week. . In order to stretch cicatricial bands, the 



PELVIC INFLAMMATORY DISEASE 433 

vagina should be systematically tamponed with the patient in the knee- 
chest position, which most favors the restoration of the uterus to its normal 
position. With these tampons considerable pressure may be made without 
danger. The smaller sizes should be used and the vaginal canal packed as 
firmly as is consistent with comfort. 

Pelvic massage, if it is ever useful, is indicated in chronic uncomplicated 
cellulitis. It may be employed by the physician each time before he makes 
an application of tampons. 

PELVIC H JEM ATOM A 

Etiology and Pathology. — Collections of blood confined to the cellular 
tissue of the pelvis are spoken of as hsematoma. They are of extreme 
rarity. Haematorna may be caused by the rupture of varicose veins in the 
broad ligament ; by hemorrhage from the cervical branches of the uterus 
after extensive operation on the cervix, or by the rupture of a tubal preg- 
nancy between the layers of the broad ligament. This is the rarest of all 
modes of termination of a tubal pregnancy. 

Symptoms. — The symptoms come on suddenly and consist of intense 
pain, and, if the bleeding is marked, the symptoms of internal hemorrhage 
will be present. 

Diagnosis. — A diagnosis will rarely be made, as the condition is so in- 
frequent. In the presence of pelvic hsematoma examination shows a mass in 
the broad ligament intimately associated with and to one side of the uterus, 
not behind it. There are no signs of peritonitis. 

Prognosis. — A hematoma usually undergoes absorption. It may burst 
into the vagina, rectum, bladder, or the free peritoneal cavity. It may be- 
come infected and suppurate. Absorption of the blood is slow, but there 
is less tendency to bad after-results than in the case of hematocele, be- 
cause the peritoneum has not been involved and there are no intra- 
peritoneal adhesions. 

Treatment. — The patient should be kept quiet in bed. An ice-cap should 
be placed over the lower abdomen. After the haematorna is fully developed, 
hot douches and local and general depletory measures should be adopted. 
In those cases in which improvement does not follow, palliative measures 
should be discarded and the haematorna should be opened and drained by 
means of a vaginal incision (Figs. 382 and 383). 

OPERATIVE TECHXIC 

Hysterectomy for Pelvic Inflammatory Disease. — After the usual pre- 
liminary preparations, an incision is made in the median line, the patient 
being in the horizontal position. If there is any fluid in the pelvis, it should 
be carefully sponged away. The patient is placed in the Trendelenburg 
posture, and the intestines packed or! as extensively as possible from the 
pelvis. The diseased ovaries and tubes should be gently freed from the 
structures to which they are adherent. This may be done entirely by the 
sense of touch, but it is preferable to keep the operative area in constant 
view, so as to avoid injury of the rectum, the small intestine, or the bladder. 
The finger should seek first for a spot of cleavage and the enucleation should 
28 



434 GYNECOLOGY 

begin on that side where it appears to be most feasible. No force should 
be employed in separating the adhesions, the palmar surface of the finger 
being always directed anteriorly toward the broad ligament rather than 
posteriorly, as, with this precaution, injury to the sigmoid or the rectum is 
less likely. An occasional snip with the scissors or nick with a sharp scalpel 
will be advisable when the adhesions are difficult to separate. After the 
adnexa and the posterior surface of the uterus are free, the fundus is caught 
with forceps, pulled up into the incision, and then hysterectomy proceeded with 
in the usual way, as has been described in Chapter XVII, page 317, the succes- 
sive steps of the operation being: (1) Ligation of the ovarian and the round 
ligament vessels on each side ; (2) clamping the uterine extremity of the 
tube, round ligament, and utero-ovarian ligament on each side to control 
the reflux circulation; (3) dividing the broad ligaments down to the supra- 
vaginal cervix; (4) incising the vesical reflexion of the peritoneum; (5) 
ligating the uterine artery on each side ; (6) amputating the body of the 
uterus by means of a wedge-shaped incision through the cervix ; (7) closure 
of the cervical stump with catgut ; (8) suspension of the cervix to the round 
ligaments ; (9) peritonealization, making use of the vesical reflexion of 
the peritoneum. 

Variations from the usual technic will be required according to the 
exigencies of the case. When there are adhesions between the pelvic struc- 
tures and the omentum, they must be freed before the abdomen is walled 
off; this is done either by separating the adherent surfaces, or by dividing 
the omentum between two ligatures. Lightly adherent coils of small or 
large intestine must be released. The pelvis is now cleared of fluid and the 
patient having been placed in the Trendelenburg position, the omentum with 
the free coils of intestine may then be displaced upward above the brim of 
the pelvis, and the gauze pack introduced. If there is any portion of the 
intestine so adherent that one fears its liberation may release a collection of 
pus, no attempts should be made to free the gut until the Availing off has 
been completed. After such intestinal coils have been released, usually they 
may be covered with hot, moist packs and kept in Douglas' pouch without 
increasing the technical difficulties of the operation. If it appears very de- 
sirable to get them out of the operative area and no pus has been set free, 
the pelvis and the intestine should be carefully cleansed with hot, moist sponges, 
the original walling-off gauze should be removed, the intestines lifted above 
the pelvic brim, and a fresh gauze pack introduced. 

In cases of tubal or ovarian abscess, it may be at once apparent upon 
inspecting the pelvic organs that the adhesions are so widespread or the 
amount of exudate is so great that any attempt at a radical removal of the 
diseased organs will expose the patient to unwarranted danger. Under such 
circumstances the intraperitoneal collection of pus should be drained from 
below through a posterior vaginal incision (Figs. 382 and 383). In difficult 
cases the hand inside the abdomen may be used as a guide in reaching the 
abscess. If evacuation from below is not feasible on account of the inter- 
vention of intestine between the posterior vaginal fornix and the diseased 
area, an extraperitoneal incision through the abdominal parietes may be 
possible, the hand in the abdomen again being a guide, or if there is no extra- 



PELVIC INFLAMMATORY DISEASE 



435 



peritoneal method practicable, the abscess ma}- be drained through the lower 
end of the celiotomy incision, the area being well walled off with rubber- 
dam and gauze. 

If the adnexal adhesions of one side are especially dense, or the adnexal 
mass is so low in the pouch of Douglas that there is danger of wounding the 




Pig. 384 



Fig. 385 



Fig. 386 



X, 



Fig. 384.- — Salpingo-oophorectomy. Points of ligation and line of excision. 
Fig. 385. — Salpingo-oophorectomy". Suture of cornua and beginning peri- 

tonealization. 
Fig. 386. — Salpingo-oophorectomy. Suture of cornua and completion of peri- 

tonealization. 



intestine or the large pelvic veins by forcible or persistent attempts to re- 
lease them from above, the hysterectomy may be started on the least affected 
side, and after the cervix has been cut through and disinfected, the difficult 
side may be approached from below upward. This will often prove the 
solution of an otherwise perplexing and dangerous situation. 



436 



GYNECOLOGY 



There are some cases in which the uterus is so densely bound down by 
adhesions, and both adnexa are so intimately incorporated with the sur- 
rounding structures, that a more favorable method of approaching enuclea- 
tion is by first bisecting the uterus in the median line from the fundus to the 
supravaginal cervix, then cutting through the cervix on one side to the 
uterine artery and ligating it, next enucleating the half uterus and the adnexa 




Fig. 387. — Salpingo-oophorectomy 



Posterior fixation of round ligament on left and Webster- Baldy 
suspension on right. 



of that side, the enucleation being carried out from below upward, and the 
vessels tied in that sequence, and then carrying out the same procedure on 
the opposite side. No drainage is required unless the case is recent. 

Salpingo-oophorectomy. — After the preliminary preparations have been 
carried out, a median abdominal incision is made and the affected area iso- 
lated by means of gauze pads. A ligature is then passed through the clear 







Fig. 388. — Salpingectomy. Points of ligation and lines of excisic 



space in the infundibulo-pelvic ligament and tied, thus controlling the 
ovarian circulation. A second ligature is then placed about the utero- 
ovarian ligament close to the uterus and a third about the utero-ovarian 
anastomosis at the uterine cornu just beneath the inner extremity of the tube 
(Fig. 384). The circulation of the ovary and tube being then secured, the 
infundibulo-pelvic and the utero-ovarian ligaments should be cut, the ovary 



PELVIC INFLAMMATORY DISEASE 



437 



and tube pulled up, and the broad ligament divided close to the adnexa as 
far as the uterine insertion of the tube. At this point the tube is removed 
from the uterine cornu by a wedge-shaped incision. The V-shaped open- 
ing of the uterine cornu is closed with a series of interrupted sutures, and 
any bleeding points along the cut surface of the broad ligament are caught 
with forceps and ligated individually (Fig. 385). A running suture is then 
carried from the infundibulo-pelvic ligament stump to the uterine cornu, 




tic. 389. — Salpingectomy. Sutuie of cornua. 

approximating the cut edges of the anterior and posterior surfaces of the 
broad ligament and covering all raw areas (Fig. 386). 

Salpingectomy. — After the usual preliminary preparations, median in- 
cision, and isolation of the operative area, the tube is released from adhesions 
and held up so that the vessels in the mesosalpinx can be plainly seen. The 
blood supply of the tube is then secured by a series of ligatures, usually 
three, from the outer to the inner extremity, placed close to the under sur 
face of the tube, so as to disturb the ovarian branches as little as possible 




Fig. 390. —Salpingectomy. Peritonealization, when short- 
ening of round ligament is not required. 

As a rule, there is an outer, a middle, and an inner uterine branch to be 
secured (see Fig. 388). The mesosalpinx should be divided along the line 
of its attachment to the tube. The tube is separated from the uterine cornu 
by a wedge-shaped incision. The incision is closed with interrupted sutures 
(Fig. 389). Bleeding points are caught and tied individually and the raw 
surface of the mesosalpinx is turned in with a continuous suture (Figs. 
390, 391, and 392). 



438 



GYNECOLOGY 



Salpingostomy. — After the usual preparations — median abdominal in- 
cision and isolation of the affected part — the diseased outer portion of the 
tube is cut away. The division of the peritoneal coat and the division of the 
mucosa are made in different planes, so that the mucosa will project slightly 
beyond the serosa. The line of excision should be oblique to the long axis 




Fig. 391. — Salpingectomy. Peritonealization, with short- 
ening of round ligaments, first step. 

of the tube. The mucous membrane lining the tube is then united to the 
outer peritoneal surface by a series of interrupted sutures of fine catgut 
(Fig. 380). A fine probe should be passed as far as the isthmus to demon- 
strate that the tube is patulous. It is usually impracticable without trauma 
to pass the ordinal surgical probe even of small caliber beyond that point 




Fig. 392. — Salpingectomy. Peritonealization, with shortening of 

round ligaments, second step. • ■ 

even in normal tubes. The tube should be washed out thoroughly with 
sterile salt solution. 

Vaginal Incision and Drainage. — After the usual preliminary prepara- 
tions, the site of the abscess is accurately located by means of bimanual 
palpation. The posterior lip of the cervix is grasped with a tenaculum and 
steadied, and a transverse incision is made back of the cervix at the reflexion 
of the posterior vaginal fornix (Fig. 382). The finger is then introduced 



PELVIC INFLAMMATORY DISEASE 439 

into the cellular tissue, and a further careful palpation made. After the 
site of the proposed puncture has been accurately located, the end of a 
sharp-pointed curved scissors is thrust into the objective point. A char- 
acteristic sensation will be imparted to the hand as the point of the scissors 
enters the abscess cavity. The blade of the instrument is separated as it is 
withdrawn, thus enlarging the opening (Fig. 383). After the evacuation 
of the pus a T-shaped soft-rubber drainage tube is introduced, and packing 
is placed in the vagina to hold the tube in position. 

BIBLIOGRAPHY 

Anspach, B. M. : " Inflammatory Diseases of the Pelvis.'' International Clinics, 1917, ii, 
27th Series. 

Baldy, J. M. : " Hysterectomy for Suppurative Disease of the Pelvic Organs." Am. Gyn. 
and Obst. Jour., Sept., 1895. 

Bernutz: Pelvic Peritonitis, Clinical Memoirs of the Diseases of Women. Bernutz 
and Goupil, vol. xi, New Sydenham Soc, London. 1867. 

Bublitschenko : " liber Sepsis puerperalis Staphylococcia." Zent. f . Gyn., 1914, xxxviii. 

Emmet, T. A. : " Pelvic Inflammations or Cellulitis versus Peritonitis." Trans. Amer. Gyn. 
Soc, 1887, ii, 101. 

Gellhorn, G. : " Salpingostomy and Pregnancy." Trans. Amer, Gyn. Soc, 191 1, xxxvi, 186. 

Harrar, J. A.: " Puerperal Infections." Bull. N. Y. Lying-in Hosp., 191 1, p. 166. 

Ill, E. J. : " The Cause, Diagnosis and Nonsurgical Treatment of Pelvic Inflammation." 
Amer. Gyn. and Obst. J., Sept., 1900. 

Kelly, H. A. : "Vaginal Drainage for Pelvic Abscess." Kelly and Noble, Gynec. and 
Abdom. Surg., 1, xviii ; Ibid.: "The Removal of Pelvic Inflammatory Masses by the 
Abdominal Bisection of the Uterus." Amer. J. Obst., 1900, xvii. 

Martin : Die Krankh. des Beckenbindegewebes u. des Beckenbauchfells. Handb. der 
Krankh. der Weib. Adnexorgane. Berlin, 1906. 

Miller,, quoted by Kelly: Operative Gynecology, 1899, vol. ii, p. 211. 

Miller, G. B. : " The Occurrence of the Streptococcus Pyogenes in Gynecological Diseases." 
Amer. Jour. Obst., 1899, xxxix, 780. 

Miller, H., and Chalfant, S. : " Treatment of Puerperal Blood-stream Infection by the 
Means of Arseno-Benzol." Trans. Amer. Gynec. Society, 1918, p. 269. 

Marmorek : " Sur le Steptococque." Comptes rendus de la Soc. de Biol., 1895, 10 me. Serie 
ii, 122; Ibid.: " Streptococque et le Serum Antistreptococque." Annales de lTnstitut 
Pasteur, 1895, vol. ix, p. 593. 

Noble, C. P.: "Puerperal Pelvic Cellulitis and Puerperal Peritonitis." Amer. Gyn. and 
Obst. Jour., Jan., 1895. 

Polak, J. O. : " The Preservation of the Menstrual Function." Jour. A. M. A., 1917, lxix, 
1938 ; Ibid. : " Observations of Two Hundred Twenty-seven Cases of Ectopic Preg- 
nancy." Amer. Jour. Obst., 1915, lxxi, 946 ; Ibid. : " Preservation of Menses in Double 
Suppurative Disease of the Adnexa." Trans. Sec. O. G. and A. S. — A. M. A., 1917, p. 174. 

Polk: "Hysterectomy (Suprapubic) for Salpingitis and Ovaritis." N. Y. Jour. Gyn. and 
Obst., Dec, 1893. 

Pozzi : " De la resection et de L'ignipuncture de L'ovaire." Rev. de Gyn., 1897. 

Simpson : "A Precise Method of Choosing a Safe Time for Operation in Pelvic Inflam- 
mation of Tubal Origin." Trans. Amer. Gyn. Soc, 1915, xi, 166 : Ibid. : " Choice of 
Time for Operation for Pelvic Inflammation of Tubal Origin." Trans. Amer. Gyn. 
Soc, 1909, p. 161. 

Tait : Diseases of Women and Abdominal Surgery. Phila., 1889. 

Williams, J. W. : Obstetrics. N. Y., Appleton, 1903. 



CHAPTER XXII 
DISEASES OF THE URETHRA 

URETHRITIS 

Etiology. — Urethritis, or inflammation of the urethra, is due, in the 
majority of cases, to direct gonorrhceal infection during coitus. Urethritis 
may also be caused by infection resulting from the introduction of an un- 
clean catheter or sound. Irritation from the use of strong chemical solu- 
tions and the trauma incident to difficult labor may be factors in the produc- 
tion of urethritis. In urethritis caused by the gonococcus the disease passes 
through an acute stage and then gradually becomes chronic. Urethritis due 
to other forms of infection and secondary to irritation caused by powerful 
chemical solutions or to traumatism, almost never becomes chronic, and 
tends to undergo spontaneous and complete cure. Both acute and chronic 
urethritis may be associated with involvement of the bladder. 

ACUTE GONORRHCEAL URETHRITIS 

Symptoms. — As the female urethra is comparatively short, the symp- 
toms are not so violent as are those of acute gonorrhceal urethritis in the 
male. The most common symptom is a frequent desire to empty the 
bladder. Urination is accompanied by a burning and scalding pain, fol- 
lowed, in the most severe cases, by the passage of a small quantity of blood. 
There is a purulent discharge from the urethra, which irritates the vestibule 
and the surrounding vulvar mucous membrane. There may be slight eleva- 
tion of temperature. 

Diagnosis. — On inspection the external meatus is found to be reddened 
and swollen, and filled with a purulent discharge. At times the mucous 
membrane is seen to bulge, as in urethral prolapse. Upon making pressure 
along the under surface of the urethra at the vaginal introitus pus may be 
expressed from the urethra or from Skene's tubules (Fig. 115). Immedi- 
ately after urination the urethra may be free from purulent discharge, but 
pus may usually be expressed from Skene's tubules or other crypts in the 
urethral floor near the meatus. 

Prognosis. — After a few days, as a rule, the subjective symptoms be- 
come less violent, the formation of pus decreases, and the other local mani- 
festations of inflammation subside. In the course of a few weeks the 
urethra may to a great extent rid itself of the disease, but the infection is 
likely to persist in Skene's tubules and in the crypts and lacunae along the 
floor of the urethra. 

Treatment. — Acute gonorrhceal urethritis may be followed by cystitis, 
but this is not especially likely to occur unless the patient is catheterized or 
local applications are made to the urethra. For this reason local treatment 
of the urethra during the acute stage of gonorrhceal urethritis is absolutely 
contraindicated. The patient should be placed upon a bland liquid diet, and 
440 



DISEASES OF THE URETHRA 441 

be instructed to drink large quantities of water. A mild urinary antiseptic, 
such as salol, combined with a diuretic salt, to render the urine as bland as 
possible, should be prescribed. For this purpose such a combination as salol 
and sodium bicarbonate is of particular value. If the urethritis is accom- 
panied by vulvitis, the treatment outlined in Chapter XI, page 167, may be 
combined with that just described. 

Other Forms of Acute Urethritis. — Acute urethritis, the result of strep- 
tococcus, diphtheritic, or virulent staphylococcus infection, may rarely be 
observed as a part of instrumental, post-abortal, or post-partal infection, and 
is usually accompanied by severe systemic disturbance. In these cases no 
treatment directed specifically toward the urethra itself is required. A 
urinary antiseptic, such as hexamethylenamine, may be prescribed. The 



k 




Fig. 393. — Disinfection of Skene's tubules with hypodermic syringe and 
blunt needle. 

patient should be encouraged to drink large quantities of water, and gen- 
eral supportive treatment should be instituted. Acute urethritis due to 
powerful chemical irritants, such as strong solutions of silver nitrate, phenol, 
or mercury bichloride, in the early stage requires no treatment beyond rest 
and the administration of soothing diuretic mixtures. The patient should 
be given large quantities of water, and combinations such as have been 
suggested for acute gonorrhceal urethritis should be prescribed. As the 
disease subsides and the purulent discharge disappears the occasional pas- 
sage of a well-lubricated urethral sound may prevent the formation of 
a stricture. 

CHRONIC GONORRHCEAL URETHRITIS 

Acute gonorrhceal urethritis subsides in the course of a few weeks, 
to be followed by the subacute and later by the chronic stage. If no 
treatment whatever is instituted, the manifestations of the disease be- 



442 GYNECOLOGY 

come progressively less and the subjective symptoms may even disappear 
entirely. At this time the urethral mucosa throughout the greater part 
of its extent has become restored to its normal condition. In the 
crypts of the urethral floor, toward the external urinary meatus, and in 
Skene's tubules the disease persists, and the infectious products are from 
time to time discharged from these foci into the urethra. Under such cir- 
cumstances the acute symptoms of urethritis may be relighted by certain 
forms of irritation (unfamiliar coitus, alcoholic excesses) ; it may extend to 
other parts of the genital tract, or it may be transmitted to another person. 

Symptoms. — There may be no subjective symptoms. As a rule, there 
is frequency of urination accompanied by pain during or after the act, and 
the patient may be conscious of a slight moisture or discharge about 
the vestibule. 

Diagnosis. — The diagnosis of chronic gonococcal urethritis is dependent 
upon the presence of pus in the urethra or in Skene's tubules, about the 
external urinary meatus, and the demonstration of the gonococcus in stained 
smears. If the patient uses a vaginal douche or empties her bladder imme- 
diately before the examination, the evidence of chronic urethritis may be 
destroyed. The examination should, therefore, be made while the bladder 
is full and without preparatory douching. In the majority of cases inspec- 
tion of the meatus shows an everted, reddened, granular mucosa, with the 
orifices of Skene's tubules exposed to view. The reddening of the mucosa 
may be limited or especially pronounced in the immediate vicinity of the 
orifices of Skene's tubules, with the formation of the so-called gonorrhceal 
macules. At times, especially in nulliparae, the lips of the meatus must be 
separated to expose the orifices of the tubules, but this is exceptional. The 
meatus and the surrounding mucosa of the vestibule should now be cleansed 
of surface discharge ; the examiner's finger should be inserted its full 
length into the vagina, and the contents of the urethra milked out by 
forward pressure upon the anterior vaginal wall. A whitish, creamy, or 
thin, murky discharge will be expressed from the urethra itself, from Skene's 
tubules, or from lacunae in the floor of the urethra just within the orifice. 
Smears of this discharge should be made as described on page 123. 

In cases giving rise to symptoms, or in those in which the process has 
recently been relighted by unaccustomed sexual intercourse or other forms 
of irritation, the gonococcus will usually be unmistakably recognizable. In 
mixed infections, or in the very old, latent cases in which no symptoms are 
manifest, it may be impossible to demonstrate the presence of the gono- 
coccus. Under such circumstances the complement-fixation test may be 
applied. If this is not available, the diagnosis must rest on the clinical 
evidences of the disease (see Gonorrhoea, page 556). 

A whitish discharge from the urethra is not always purulent, but may 
be made up almost entirely of desquamated epithelium. This is especially 
prone to occur in chronic cases that have been exposed to active 
local treatment. 

Treatment. — The treatment of subacute or chronic gonorrhoeal urethritis 
consists of the administration of urinary antiseptics and direct applications 
of gonococcides to the urethra. 



DISEASES OF THE URETHRA 443 

The bland refrigerant diuretics prescribed in the acute stage should be 
replaced by hexamethylenamine and sodium benzoate, or by the oil of 
sandalwood and copaiba. 

Local Treatment. — Local treatment should be carried out by the phy- 
sician, for it is impracticable for the patient to apply it herself. In the 
subacute or chronic stage the disease is confined largely to the vicinity of the 
external meatus. This local treatment consists, first, of massage, applied 
for the purpose of emptying the urethra and all the urethral crypts of dis- 
charge, the manipulations being made through the anterior vaginal wall, 
and performed at a time when the bladder is full. After the urethra and the 
crypts have been emptied of pus, the patient is instructed to urinate, thus 
washing clean the urethral mucosa. By means of a blunt-pointed hypo- 
dermic needle Skene's tubules may then be injected with a solution of 
ichthyol, argyrol, or silver nitrate (Fig. 393). The tubules or crypts are 
located, the blunt needle carefully introduced as far as it will go, and the 
crypt washed out first with sterile water. As a gonocide there is noth- 
ing superior to silver nitrate, the solutions varying in strength from 2 to 10 
per cent. Later normal salt solution may be injected to inhibit the action 
of the silver nitrate. 1 

Argyrol (20 per cent.) and protargol (1 to 5 per cent.) are valuable 
gonocides, and may be used instead of the silver nitrate. Ichthyol (25 to 
50 per cent.) and Churchill's tincture of iodine are also reliable preparations. 
The urethra itself may now be treated. The hypodermic syringe should 
be fitted with a probe-pointed cannula of small caliber and two inches in 
length. The cannula is passed to the neck of the bladder, which is com- 
pressed by a finger in the vagina, and the urethra is flushed with sterile 
water. This maneuver is repeated several times, each withdrawal of the 
cannula being followed by gentle massage. The solution of gonocide is 
now injected, care being taken to compress the vesical end of the urethra 
beyond the point of the cannula. For this purpose one of the following 
preparations may be used: Silver nitrate (2 to 10 per cent.), followed by 
salt solution; argyrol (20 per cent.) ; protargol (5 to 20 per cent.) ; iodine 
(2 to 5 per cent.) ; ichthyol (10 to 50 per cent.). In order to further the 
action of the antiseptic, a urethral tampon saturated with a bland anti- 
septic solution should be applied (Fig. 394). The tampon is made by roll- 
ing a thin layer of cotton loosely upon the end of an applicator. The entire 
length of the tampon should not be over one and one-quarter inches. It 
is moistened with the solution, and introduced by means of the applicator 
into the urethra, up to the internal urinary sphincter. The applicator is 
then withdrawn. From ten to fifteen drops of the solution are now in- 
jected into the urethra by means of the probe-pointed cannula or blunt 
hypodermic needle (Fig. 395), the tampon taking up the injected fluid, and 
securing a more or less continuous application of the remedy to the urethral 

1 For the injection of silver nitrate an all-glass hypodermic syringe should be used in 
preference to the all-metal or partly metal ones, since the precipitate formed by the action 
of the silver nitrate on the metal will obstruct the lumen of the needle. For the same 
reason silver solution should not be allowed to remain in contact with the needle for 
any length of time. After injecting the solution the needle should be flushed out and a 
stvlet introduced. 



444 



GYNECOLOGY 



mucosa until the next act of urination, when it is expelled. The urethral 
tampon may be saturated with any of the solutions mentioned, but where 
silver nitrate or iodine is employed, weak solutions (i per cent.) must be 
used at first, and the effect carefully noted before their strength is increased. 
As a rule, it is better to use silver nitrate and iodine for the urethral injec- 
tion, and argyrol, protargol, or ichthyol for the tampon. The treatment 
should be repeated daily, or as often as is practicable, in order quickly to 
rid the patient of the disorder and prevent it from becoming chronic. As a 
result of this treatment the discharge becomes diminished in amount, and a 
microscopic examination shows that many epithelial and few pus-cells are 
present, while the gonococci are few in number. At this stage it is well to 
substitute a slightly astringent antiseptic solution, such as zinc sulphate 
(15 grains), powdered burnt alum (15 grains), phenol (4 grains), water 
(enough to make 4 ounces). Careful treatment, repeated at intervals, and 




Fig. 394. — Urethral tampon in position. 



Fig. 395. — Saturating urethral tampon with 
hypodermic syringe and bulbed cannula. 



the avoidance of reinfection are almost certain to effect a cure. In those 
persistent cases in which it seems impossible, in spite of treatment, to free 
Skene's tubules of the infection, a favorable result may be secured by lay- 
ing them open freely with a sharp bistoury and cauterizing with pure phenol. 
(For the vaccine treatment of chronic gonorrheal urethritis see Chapter XLI.) 
Other Forms of Chronic Urethritis. — A form of chronic posterior ure- 
thritis, with or without contraction or stricture formation of large caliber, 
is declared by Hunner to be the sequel of infection and inflammation of the 
tonsils and accessory nasal sinuses, teeth, gastro-intestinal tract, etc. In 
these cases the urethritis may be difficult to explain on other grounds in 
virginal, chaste women. The urethroscopic picture and symptoms are not 
characteristic. The condition is quite amenable to local treatment — e.g., 
dilatation of the urethra and the application of silver nitrate — but recurs at 
more or less frequent intervals. Removal of the focus of infection has given 
very striking results in some of Hunner's cases. 



DISEASES OF THE URETHRA 445 

SUBURETHRAL ABSCESS 

Etiology. — A suburethral abscess results from infection of a suburethral 
crypt, with subsequent complete or partial blocking of the communication 
of the crypt with the urethra. The collection of pus lies within the floor of 
the urethra, in close approximation to the anterior vaginal wall. The size 
of the abscess is, on the average, that of a marble, but it may vary in dimen- 
sions from a pea to an egg. 

Symptoms. — The subjective symptoms are similar to those of acute or 
chronic urethritis, but are somewhat exaggerated, depending upon the ex- 
tent of the disease. In addition there is a feeling of fullness and distress in 
the affected parts, entirely independent of urination. 

Diagnosis. — By palpation the abscess may readily be detected as a 
tender nodule or globular tumor embedded in the urethrovaginal septum. 
In the case of larger abscesses there may be a considerable projection of the 
mass into the vagina. Upon passing a fine probe along the floor of the 
urethra the original opening of the crypt may occasionally be found, and 
the probe introduced through it to the bottom of the sac, where the end of 
the probe may be felt by the vaginal finger. The mouth of the infected crypt 
may be brought into view by means of the urethroscope, and pressure on the 
sac may result in the escape of pus into the urethra. 

Treatment. — When a communication can be found with the urethra and 
the sac is small, the pus may be evacuated by gentle pressure, and a cure 
effected by keeping the crypt open and using repeated injections of anti- 
septic solutions. If the sac is of considerable size, however, a cure will not 
be obtained without free drainage, and this can best be secured by making 
vaginal incision. The pus should be evacuated and the interior of the sac 
swabbed with pure phenol and allowed to heal by granulation. If the com- 
munication between the abscess and the urethra is completely sealed, the 
sac should be enucleated from the vaginal side, without rupture, if possible, 
and the wound immediately closed. 

URETHRAL FISSURE 

Urethral fissure usually occurs at the internal urinary meatus, and con- 
sists of a linear crack or ulcer in the mucosa embraced by the 
sphincter muscle. 

Etiology. — The condition results from urethritis or traumatism, such as 
follows repeated catheterization or the passage of a calculus. It is similar 
to a fissure in ano, and may be as troublesome and as persistent. The 
vesical sphincter is usually hypersensitive and spastic. 

Symptoms. — The symptoms consist of pain after urination, with or 
without a frequent desire to repeat the act. The urine may contain 
red blood-cells. 

Diagnosis. — The diagnosis may be made by means of a cylindric (Kelly) 
cystoscope. The instrument is passed into the bladder, the urine is evacu- 
ated, and the speculum is slowly withdrawn. As the internal meatus 
closes over the end of the speculum the fine linear fissure or fissures 
may be discerned. Gentleness, to avoid traumatism, an excellent light, and 



446 GYNECOLOGY 

small pledgets of cotton for sponging are essential to success. The treat- 
ment consists in overstretching and temporarily paralyzing the vesical 
sphincter by the passage of a sound several sizes too large. This pro- 
cedure alone may be sufficient. If it is not, in addition to the passage of 
the sound the fissure should be painted with a solution of silver nitrate, or 
the muscle may be incised with a small, delicate, especially constructed knife. 
Usually, however, such heroic treatment will not be required. 

PROLAPSE OF THE URETHRAL MUCOSA 

Etiology. — The mucosa of the urethra may become loosened from the 
underlying tissues and protrude through the external urinary meatus (Fig. 
397). This condition is commonly a late result of injury received during 
labor. It is usually accompanied by other evidences of traumatism, such as 



Fig. 396. — Self -retaining or mushroom catheter. 

vaginal scars in the anterior or posterior wall, cystocele, and rectocele. The 
associated lesions often are slight and manifest no symptoms. Prolapse of 
the urethra is seen especially about the time of the menopause, when there 
is a certain amount of atrophy and shrinkage of the vulvar parts. Prolapse 
of the urethral mucosa may be a complication of urethritis, or it may follow 
long-continued cystitis or vesical tenesmus. In some cases occurring in 
virgins, the causative factor cannot be determined. 

Symptoms. — There may be few or no symptoms or the prolapsed mucosa 
may be exquisitely tender and sensitive and give rise to an almost constant 
desire to urinate, pain and soreness accompanying the act. These cases 
resemble closely those of urethral caruncle, and, indeed, in some, in addi- 
tion to prolapse of the entire circumference of the meatal mucosa, there is a 
localized and sensitive hypertrophy that resembles a caruncle. 

Treatment. — In mild cases the prolapsed and sensitive mucosa may be 
treated with silver nitrate (10 per cent, solution) followed by the applica- 



DISEASES OF THE URETHRA 



447 



tion of a soothing ointment. In marked 
cases the parts should be cocainized and 
the protruding mucosa ligated in sections 
and snipped off. When the prolapse is ex- 
tensive, general anaesthesia may be in- 
duced, and excision of the prolapsed 
mucosa, followed by the formation of a 
new external meatus, carried out. Care 
should be taken, in the construction of the 
latter, to obviate the tendency to protru- 
sion of the mucous membrane. This may 
be done as indicated in the accompanying 
illustrations (Figs. 397 to 399). When the 
prolapse of the mucosa is complicated 
with a cystocele or other lesions of the 
adjacent structures, such as cystitis, ure- 
thritis, etc., appropriate treatment for 
these conditions should be instituted. 




Fig. 
397 




URETHRAL DILATATION 

Etiology. — The urethra may possess 
an abnormally large lumen congenitally, 
but dilatation of the urethra, as a rule, 
results from various forms of traumatism. 
When the external genitalia are defective, 
e.g., when there is atresia of the vagina, 
etc., repeated attempts at copulation in 
rare instances result in a gradual dilata- 
tion of the urethra. This may become so 
marked that the penis may enter the blad- 
der during coitus. Copulation per ure- 
thram has been said to be compatible with 
excellent control of the bladder. In one 
case recently observed, the urethra 
had been split bilaterally back to the in- 
ternal urinary meatus, the resulting pas- 
sage being used regularly for copulation, 
in spite of the fact that the patient suffered 
from constant dribbling of urine. 

Urethral dilatation occurs most com- 
monly in the child-bearing woman, and is 
caused by lacerations of the urethral mus- 
culature, especially of the fibers at the in- 
ternal urinary meatus, and by the loss of sup- 
port normally afforded to the urethra by the anterior vaginal wail. Other causes 
may be: An overstretching of the canal, with rupture of some of the circular 
muscle-fibers, as from the passage of a cystoscope or sound that is too large. A 
stricture or a new growth of the urethra or of the neighboring parts that 



Fig. 
398 



0S f 

4 



Fig. 
399 



Fig. 397.- 
Fig. 398.- 
Fig. 399.- 



Prolapsed urethral mucosa. Outline 

of denudation. 
Prolapsed urethral mucosa. Denu- 
dation completed. 
Prolapsed urethral mucosa. Sutures 
introduced. 



448 



GYNECOLOGY 



Co^veX exr 






impedes the expulsion of urine may produce a dilatation of the urethra be- 
hind the point of obstruction. Incontinence of urine due only to a lesion 
of the vesical sphincter is relatively infrequent. Incontinence due to a 
lesion of the sphincter plus other pelvic lesions is frequent. 

Symptoms. — The most common symptom of dilatation of the urethra is 

an inability to control the pas- 
sage of urine. In the usual 
type, i.e., that seen in the child- 
bearing woman, any sudden 
or violent increase of intra- 
abdominal pressure, such as is 
induced by lifting, coughing, 
sneezing, or laughing, will be 
followed by a more or less free 
and continuous leakage of 
urine. In some instances a 
perineal dressing must be 
worn almost constantly. 

Diagnosis. — In a majority 
of cases the external orifice 
gapes widely, exposing the 
mucosa of the interior. The 
neighboring parts are erythe- 
matous from the constant 
moisture, and coughing, bear- 
ing down, etc., result in drib- 
bling of urine. A sound is 
passed without difficulty, and 
the external urinary meatus 
will admit a much larger sized 
instrument than under normal 
conditions, e.g., Nos. 28 to 
30 F. An acorn bougie will 
help determine whether the 
condition is localized or gen- 
eral. In the ordinary case the 
dilatation is particularly notice- 
able at the external urinary 
meatus, and there are asso- 
ciated lesions that have been 
produced by the same agency 
that caused the urethral dilata- 
tion, viz., the traumatism inci- 
dent to labor. There is almost always some degree of cystocele and rectocele. 
The vaginal outlet may be moderately or excessively relaxed, and the uterus is 
often in a state of descensus or prolapse. 

Treatment. — In the very rare cases of excessive dilatation of the urethra 
resulting from coitus per urethram, an effort must be made to restore the 




Fig. 400. — Operation for relaxation of vesical neck of urethra. 
First step; mucosa dissected and a mattress suture inserted. 
Fig. 401. — Operation for relaxation of vesical neck of urethra. 
Second step, mattress suture tied, outline for removal of 
redundant mucosa. 



DISEASES OF THE URETHRA 449 

vagina (see Atresia, page 28) and then to narrow the urethral canal by 
performing plastic operations, to be described further on. 

In the common form of urethral dilatation, that due to injuries received 
during labor, the associated conditions of relaxation and displacement must 
be corrected. Temporary relief is often secured by the wearing of a pessary, 
which replaces and supports the sagging parts and compresses the lumen 
of the urethra. 

The surgical treatment of the urethra itself consists in reduplicating its 
inferior wall by sutures passed through the adjacent tissues and tied in the 
median line, as in the operation for cystocele (Chapter XIII). This is the 
general principle of lessening the caliber of the urethra and giving support 
to the structures. It should be supplemented by the plan here outlined, of 
locating accurately the vesical sphincter and endeavoring to catch in the 
grasp of the sutures the actual muscle fibers of the sphincter (Figs. 400 
and 401). In addition to the infolding of the vesical sphincter, care should 
be observed to remove all dragging or downward traction on the anterior 
vaginal wall. 

If the external urinary meatus is dilated and the mucosa exposed, the 
orifice should be resected, as shown in the accompanying illustrations (Figs. 
397 t° 399). The operations upon the urethra should be supplemented by 
an anterior colporrhaphy (Chapter XIII). 

STRICTURE OF THE URETHRA 

Etiology. — Whereas the external meatus may be very small congenitally, 
acquired stricture of the urethra is most uncommon in the female. It may 
result from a severe urethritis, from traumatism inflicted during labor or 
by instrumentation, or it may follow destructive cauterization or disinfec- 
tion of the urethral mucosa. It may occur in any part of the urethral canal. 

Symptoms. — The symptoms are a frequent desire to urinate, with diffi- 
culty in expulsion, accompanied by pain and vesical tenesmus. A certain 
amount of residual urine is often constantly present. 

Diagnosis. — The diagnosis is made as the result of the passage of sounds 
or acorn-tipped bougies. 

Treatment. — The treatment consists in performing gradual dilatation. 
This is usually readily accomplished, as the female urethra is comparatively 
short. In obstinate cases forced divulsion under general anaesthesia, with 
frequent passage of the sound during convalescence, may effect a cure ; or a 
permanent catheter may be left in situ until healing has occurred. 

URETHRAL CARUNCLE 

A urethral caruncle is a small tumor springing from the urethral 
mucous membrane at the site of the external urinary meatus. It is often 
flattened from side to side, presenting the appearance of a cock's comb 
(Fig. 402). Its long diameter, as a rule, lies in the median line, and it usu- 
ally springs from the posterior urethral wall. It is seen most commonly 
in women of mature years. 

Symptoms. — The tumor is exquisitely sensitive to touch, and urina- 
29 



450 



GYNECOLOGY 



tion is accompanied by severe, sometimes excruciating, pain. Urethral 
caruncle often simulates prolapse, or a redundancy of the urethral mucosa 
at the site of the external urinary meatus. The size of a caruncle is not 
in direct proportion to the amount of pain it induces, a large growth some- 
times being accompanied by very few symptoms, whereas a small one may 
be exceedingly tender. The caruncle ranges in size from a pinhead to a 
hickory-nut, and its color varies from a pale to a bright red. The tumor may 
be sessile or pedunculated, and bleeds easily. 




Ftg. 402. — Urethral caruncle (Dr. Philip Williams, Presbyterian Hospital), 
shows base attached to floor of urethra. 



Detail 



Treatment. — The treatment consists of removal of the tumor. For this 
purpose infiltration anaesthesia with novocaine { l /\. per cent.) and adrenalin 
may be sufficient ; but in nervous hypersesthetic individuals, or when the 
pain is excruciating, a general anaesthetic should be given. The growth may 
be either excised from the mucosa by a V-shaped incision, and the resulting 
wound sutured with fine catgut, or, if it is pedunculated, the pedicle may 
be ligated close to its base and the tumor snipped off. 



DISEASES OF THE URETHRA 451 

Redundancy and prolapse of the urethra, simulating in appearance small 
urethral caruncles, are not infrequently encountered in old multiparas This 
swollen mucous membrane is exquisitely sensitive and painful at times, 
whereas at other times it gives rise to no symptoms whatever (see 
Urethral Prolapse, page 446). 

NEW GROWTHS OF THE URETHRA 

Benign tumors, such as mucous polypus, fibroma, myoma, and fibro- 
myoma, are rarely encountered. The symptoms consist of frequent, painful, 
and difficuk urination, simple inspection, digital examination, or the urethro- 
scope revealing the presence of the tumor in the wall of the urethra. Enu- 
cleation and plastic repair constitute the treatment. 

Malignant tumors, such as carcinoma and sarcoma, are occasionally 
seen. Carcinoma is usually secondary to carcinoma of the clitoris or ves- 
tibule, but it may be primary in the meatus. Crossen has collected twenty- 
five cases of primary urethral carcinoma. Sarcoma is the rarest of all 
urethral tumors. 

Symptoms. — The symptoms of carcinoma and sarcoma of the urethra 
consist of frequent and painful urination and hematuria. The growth usu- 
ally presents at the external meatus and is surrounded by an area of indura- 
tion. A positive diagnosis can be made only as the result of a microscopic 
examination. 

Treatment. — The treatment consists of excision; not infrequently, however, 
the growth is not discovered early enough to permit removal without extensive 
mutilation and resulting permanent incontinence of urine. Moreover, 
metastasis takes place directly into the deep glands of the pelvis. On 
account of the direction of the lymphatic drainage, the first metastasis makes 
recurrence certain, for the affected glands are beyond reach (Crossen). 
When the case is seen early, the following plan, described by Crossen, 
should be carried out : 

First: The formation of a temporary vesicovaginal fistula for continu- 
ous drainage of the bladder ; it should be placed in the median line, near 
the posterior margin of the trigone ; a permanent catheter is introduced, 
and secured in place with a non-absorbable suture. 

Second. The growth is excised, and with it the surrounding portion of 
the vestibule and the urethra and the periurethral tissues back to the bladder. 

Third : The muscular tissue in the vicinity of the internal urinary meatus 
is now piled up above the opening by a series of two or three purse-string 
sutures of fine chromic catgut. A small catheter should be placed in the 
opening while the sutures are being tied. The mucosa should be kept 
carefully drawn out beyond the ring of piled-up tissue, so that it may subse- 
quently be sutured to the transplanted flaps. 

Fourth. Flaps for covering the raw surface are taken from the anterior 
vaginal wall. After being suitably disposed, they are sutured to each other 
and also to the stump of the urethral mucosa. (For further details the 
reader is referred to Crossen's paper.) 

The prognosis in early cases, as collected by Crossen, is fair; thus, of 



452 GYNECOLOGY 

twenty-five cases in the literature, eight cures (three years old) and three 
probable cures (two years old) were reported. In fourteen there was 
recurrence or the patient had been lost sight of. 

In all cases subjected to operation, radium should subsequently be used 
in an effort to avoid recurrence. In far-advanced cases radium is the only 
recourse, but it offers little hope of permanent cure. 

BIBLIOGRAPHY 

Crossen: "Primary Cancer of the Female Urethra; Plastic Work and Late Results." 

Trans. Amer. Gyn. Soc, 1915, xl, in. 
Hunner, G. L. : " Diseases of the Bladder and Urethra." Kelly-Noble Gynecology and 

Abdominal Surgery, Saunders, Phila., 1917 ; Ibid. : " Chronic Urethritis and Chronic 

Ureteritis Caused by Tonsillitis." Jour. Amer. Med. Asso., April 1, 191 1, lvi, 937-941. 
Keefe: " Prolapse of the Female Urethra." Trans. Sect. O. G. and A. S., A. M. A., 1917, I3 1 - 
Kelly, H. A. : " Incontinence of Urine in Women." Urol, and Cutan. Rev., June, 1913, 

xvii, 291. 
Miller, G. B. : " Incontinence of Urine Following Labor." Trans. Amer. Gyn. Soc, 1909, 

745- 
Nitze : Lehrbuch der Kytoscopie, 1889. 
Pawlik, C. : " Ueber die Harnleitersondirung beim Weibe." Arch. f. Klin. Chir., 1886, 

xxxiii, 717-739. 
Simon : tiber die Methoden die weibliche Urinblase zugangig zu machen und iiber die 

Sondirung der Harnleiter beim Weibe. Samml. klin. Vortrage, Volkmann, Leipzig. 
Skene, J. C. : " The Anatomy and Pathology of Two Important Glands of the Female 

Urethra." Amer. Jour. Obst, 1880, xiii, 265. 
Taussig : " Urethral Bacteria as a Factor in the Etiology of Cystitis in Women." Amer. 

Jour. Obst., October, 1906. 
Taylor, H. C, and Watt, C. H. : " Incontinence of Urine in Women." Surg., Gyn. and 

Obst., 1917, No. 3, xxiv, 296. 



CHAPTER XXIII 
DISEASES OF THE BLADDER 

CYSTITIS 

Cystitis, or inflammation of the bladder, may be caused by direct and 
primary infection of the organ, resulting from the introduction of unclean 
instruments, as in catheterization after labor or following operation. The 
condition may follow the extension backward of a urethritis. It may be 
secondary to an infection of the kidney (pyelitis), or may result from infec- 
tion after injury to the bladder mucosa by strong antiseptic solutions, by 
rough catheterization, or by operations upon adjacent parts during which 
the bladder has been traumatized. It may have its origin in the retention 
of urine following displacements of the uterus or obstruction to the urinary 
outflow by the pressure of extravesical tumors. It may be the result of the 
damage that has been caused by a neoplasm or a vesical calculus. Rupture 
of extravesical collections of pus into the bladder may also be the causative 
factor. It has been stated that neither the introduction of microorganisms 
nor trauma alone is sufficient to produce cystitis — that both must be com- 
bined. The most common organism found in acute cystitis is the colon 
bacillus, next in frequency being the gonococcus and the staphylococcus. In 
chronic forms the tubercle bacillus and the bacillus proteus also play a part. 
Cystitis may be acute or chronic. 

acute cystitis 

Etiology. — Acute cystitis of a mild type, limited to the trigone and 
rapidly subsiding under expectant treatment, is frequently observed in con- 
nection with acute gonorrhceal urethritis. The condition is also seen after 
operation, when the blood supply of the bladder has been disturbed and the 
mucosa has been traumatized. Acute cystitis may also follow septic and 
rough catheterization, but this is but rarely encountered as a cause at the 
present day. The condition may be secondary to and accompany an 
acute pyelitis. 

Symptoms. — The symptoms of an acute cystitis are a frequent desire 
to urinate ; burning pain during micturition, and a feeling afterward that 
the bladder has not been emptied ; an uncontrollable desire to strain,, and 
possibly the passage of a little blood. Combined with these manifestations 
there may be in the most severe cases (those due to septic catheterization), 
chilliness, elevation of temperature, and suprapubic and vaginal tenderness. 
The urine is turbid in appearance, acid in reaction, and contains a large 
amount of vesical epithelium, many bacteria, pus, and possibly blood. 

Diagnosis. — At the beginning of the attack cystoscopic examination is 
very painful, and quite unnecessary. A presumptive diagnosis may be for- 
mulated from the symptoms, and treatment instituted. As the disease sub- 
sides or passes into the chronic stage, the cystoscope will be useful in con- 

453 



454 GYNECOLOGY 

firming the diagnosis and in definitely locating the extent of the affection. 
In most cases the inflammation affects primarily the trigonum. the mucosa 

of which appears thickened, and its color a diffuse, intense red. the outlines 
of the individual blood-vessels being less distinct. In severe cases ecchy- 
motic areas and superficial ulcerations may be noted. 

Treatment. — The patient should be kept in bed. The diet should be 
limited to liquids, preferably milk. Large quantities of water should be 
taken. A refrigerant diuretic, such as the liquor potassi citratis. should be 
prescribed in full dose. Hot applications to the lower abdomen and peri- 
neum give relief, and the same is true of a prolonged hot vaginal douche. 
After the severity of the symptoms has abated somewhat, or in stubborn 
cases that show no improvement under the expectant plan of treatment, 
gentle irrigation of the bladder (Fig. 403') with warm normal salt solution 
may be advised : this often gives marked and speedy relief. The bladder 
should not be left empty after the irrigation, but partly tilled with one or 
two ounces of a 10 per cent, solution of argyrol or a 5 per cent, emulsion of 
silver iodide. The patient should be directed to hold this solution as long 
as possible. 

Prognosis. — Acute cystitis in the female usually yields rapidly to treat- 
ment, so that within a few days the patient will be comfortable. Treat- 
ment should be continued until all evidences of the disturbance have disap- 
peared, and until cystoscopic examination and urinalysis reveal normal 
conditions. If the cystitis persists, the measures described in the treatment 
of chronic cystitis must be undertaken. 

CHROXIC CYSTITIS 

Etiology. — Chronic cystitis may be secondary to an acute cystitis due to 
any cause, but it is more likely to be the result of a mild but progressive 
infection associated with conditions that prevent free vesical drainage, as in 
cases of urethral stricture, cystocele. prolapse of the uterus, and compression 
of the urethra and distortion of the bladder by pelvic new growths. Hunner 
has recently described a form of persistent chronic cystitis apparentlv due 
to hematogenous infection of the vesical mucosa from distant foci. In this 
there are small linear ulcers, especially in the fundus of the bladder, and ex- 
cision of the diseased area is often necessarv to effect a cure. 

The most severe form of chronic cystitis is the tuberculous. This con- 
dition is almost never primary, but follows tuberculosis of the kidnev. A 
chronic cystitis that persists in spite of treatment is usually tuberculous. 
Rarely there may be infection with the bilharzia. distoma haematobium, and 
the echinococcus. 

Symptoms. — The symptoms of chronic cystitis consist of frequent and 
painful micturition. The severity of the manifestations varies considerablv 
in different cases. The urine is cloudy in appearance and contains pus. 
When the disease is of recent origin and secondary to acute cystitis of the 
infectious type (caused by catheterization or gonorrhoea), the urine may be 
acid in reaction. In tuberculous cystitis the urine is also acid. If the con- 
dition is largely the result of urinary retention and decomposition, and in 
most cases of long standing, the pus-cells are less numerous, but the urine 



DISEASES OF THE BLADDER 



455 



contains myriads of bacteria and has a foul, ammoniacal or stale-fish odor, 
due to the splitting of the urea content by the staphylococcus and the 
proteus vulgaris. 

Diagnosis. — In cases of chronic cystitis produced by septic and traumatic 
catheterization or by gonorrhoea, cystoscopic examination usually shows 
that the principal seat of involvement is in the triangular area, bounded by 
the internal urethral orifice and the ureters, which is known as the trigone. 
In this area small, inflamed patches may be discerned, partaking of the 
nature of a superficial ulceration or a papillary erosion. The inflamed parts 
may be entirely confined to one area, usually that about the internal urethral 
orifice, or there may be discrete patches here and there over the entire 
trigonum and the surrounding region. 

In cases of cystitis due to retention of urine, with secondary decomposi- 




FlG. 403. — Irrigation of the bladder with a two-way catheter. 

tion and infection, as in cystocele or prolapse, there is usually a diffuse 
reddening of the mucous membrane of the affected part of the bladder, and 
frequently this area shows precipitations of urinary salts, which at first 
sight give the impression of being purulent. Upon irrigating the bladder, 
however, these precipitates may be dissolved or washed away ; microscopic 
examination will demonstrate their true nature. The urine contains pus- 
cells, myriads of bacteria, a considerable amount of mucus, and a large 
quantity of desquamated epithelium. Retention cystitis from urethral ob- 
struction often results in hypertrophy of the bladder as a whole, and par- 
ticularly of the muscular tissues of the bladder wall. Upon cystoscopic 
examination this condition is evidenced by a trabeculated appearance of 
the bladder wall, due to a hypertrophy of the muscular constituents, with 
a tendency to sacculation of the intervening areas. When the obstruction 
has been marked and persistent, this tendency results, in certain areas, in 
the formation of diverticula, which, at first sight, may resemble diseased. 



456 GYNECOLOGY 

open, and rigid ureteral orifices, and may be mistaken for them. Such 
diverticula are also due to congenital causes. 

Treatment. — The treatment of chronic cystitis other than the tubercu- 
lous variety should consist in the use of an autogenous vaccine, the administra- 
tion of urinary antiseptics, direct applications of cleansing and antiseptic 
solutions, and measures to correct conditions that produce urinary reten- 
tion. Cultures most frequently show the colon bacillus and the staphylo- 
coccus. A vaccine should be prepared from the combined growth of whatever 
organisms are found. The most reliable urinary antiseptics are hexamethy- 
lenamine and salol. The former is the most effective. Since it acts best 
in an acid medium, it should be combined with sodium benzoate if the 
urine is weakly acid, neutral, or alkaline. Salol is effective in either acid or 
alkaline urine, but an attempt should, nevertheless, invariably be made to 
restore the normal urinary reaction. Copaiba and sandalwood are efficient 
in chronic gonococcus cystitis. Daily gentle irrigations of the bladder with 
nitrate of silver 1 : 10,000 followed by normal salt solution should be used, 
or the bladder should be irrigated with boric acid and 1 or 2 ounces of 10 per 
cent, solution of argyrol, protargol, or the emulsion of silver iodide left in the 
bladder. In obstinate cases ulcerated spots may be lightly curetted or 
touched with strong solutions of silver nitrate. After the local coiidition 
has improved, the sources of retention should be removed. Thus cystocele 
and prolapse should be subjected to operation, urethral stricture should be 
dilated, and tumors compressing or distorting the bladder or urethra should 
be excised. 

Continuous drainage, such as can be provided by a vesicovaginal fistula, 
may be demanded when the case has resisted every other plan of treat- 
ment and the bladder has become intolerant of retention catheters. This 
method should be avoided except as a last resort. The formation of an arti- 
ficial vesicovaginal fistula is a simple operation. The bladder should be 
filled with boric-acid solution and the anterior wall exposed with a Sims' 
speculum. A longitudinal incision, about three-quarters of an inch in 
length, is made exactly in the median line, through the vesicovaginal 
septum. This incision should bisect the trigonum without injuring the 
internal sphincter or the ureters. The edges of the vesical and of the 
vaginal mucosa should be united by sutures. When the mucosa has healed 
— usually at the end of about six weeks — such a fistula will require opera- 
tion for closure. After making a vesicovaginal fistula for the purpose of 
securing permanent bladder drainage, care must be taken to see that the 
urine has ready exit from the vagina, or it will back up into the bladder. 
In nulliparous women and in virgins the vulvar outlet should be stretched or 
divided, if necessary, and the patient kept in the Fowler position. 

TUBERCULOUS CYSTITIS 

Etiology. — This is the most common and most serious form of chronic 
cystitis. Tuberculous cystitis is almost invariably secondary to tuber- 
culosis of the kidney. 

Pathology and Symptoms. — The condition develops insidiously. The first 
symptoms are increased frequency of urination and the presence of pus or blood 



DISEASES OF THE BLADDER 457 

in the urine. Cultures of the urine usually show no growth. In early cases c-ysto- 
scopic examination will generally reveal the fact that the bladder involve- 
ment is limited to the region of one ureteral orifice. The orifice is no 
longer linear, but, on account of the thickening and infiltration of the 
ureter, becomes rounded, open, and rigid, somewhat resembling in appear- 
ance a golf hole. The edge of the orifice may seem to be cedematous, or it 
may be dotted w T ith small, grayish miliary tubercules ; if the process is an 
older one, there may be ulcers ; in the later stage ulceration becomes more 
extensive, the ureteral opening retracts, and the entire ureteral area is 
converted into a funnel-shaped depression covered with indolent 
granulation tissue. 

The trigonum may be involved from the diseased ureteral orifice to the 
internal urinary meatus, the affection first appearing in the form of small 
grayish tubercles ; or if the tubercles have broken down, discrete ulcerated 
areas are seen covered with a yellowish-gray slough or pus. The discrete 
appearance of these areas, surrounded by a mucous membrane that, except 
for the reddening, is but little altered, has been compared to footprints 
in freshly fallen snow. 

In advanced cases of bladder tuberculosis there may be very extensive 
ulceration of the entire organ. This ulceration may have been followed by 
infiltration and contraction of the submucous and muscular coats, so that 
the normal capacity of the bladder has been very materially decreased, and 
cystoscopic examination at first is unsatisfactory, and no information can be 
ascertained from it. This is due to the fact that distention of the bladder 
and the introduction of the cystoscope are very painful, and the patient 
complains bitterly. The bladder admits of very little distention, and the 
mucous membrane is beset with ulcers covered with a grayish-yellow slough, 
or a thick yellow pus that conceals or marks the landmarks. After the in- 
gestion of large quantities of fluids and following gentle irrigation of the 
bladder daily for a time, the cystoscopic picture is much clearer, and although 
there may be considerable ulceration, oedema, or distortion of the bladder, 
it is usually possible to distinguish both the ureteral orifices. If the cysto- 
scopist is in doubt regarding them, he may have recourse to an injection of 
indigo-carmine, when the excretion of the colored urine will mark the 
ureteral site. The sensitiveness of the parts may be lessened by applying 
a 10 per cent, solution of cocaine to the urethra and by administering a pre- 
liminary injection of morphine (*4 grain) and scopolamine (1/150 grain). 

Diagnosis.— The gradual development of frequent and painful urination, 
a persistently acid pyuria, a rebelliousness to any form of treatment, a 
diminution in the capacity of the bladder, and an extreme sensitiveness are 
all suggestive of tuberculous cystitis. As a rule, there has been a previous 
indication, well marked or perhaps very vague, of a tuberculous focus else- 
where in the body. The positive diagnosis must be based upon the cysto- 
scopic findings and upon the recovery of the tubercle bacillus from the 
bladder, as shown by the injection of guinea-pigs with the urinary sedi- 
ment (recovery of the tubercle bacillus from the lymphatic glands), or the 
recognition of the bacillus in smears, as well as the detection of tuberculous 
infection in one or both kidneys. 



458 GYNECOLOGY 

Treatment. — The treatment of tuberculosis of the bladder is secondary 
in importance to that of tuberculosis of the kidney. After the tuberculous 
kidney has been removed there is usually a marked and continued improve- 
ment in the vesical condition. The improvement may be hastened by 
performing gentle irrigation of the bladder with warm salt solution and the 
instillation of iodoform in sweet oil. These instillations must be practised 
with great gentleness and care, the strength of the solution and the quantity 
instilled being gradually increased. The capacity of the bladder may be in- 
creased by encouraging the patient to retain the urine for as long a time as 
possible, and by making gentle hydrostatic pressure during the course of 
the irrigation. Direct application of strong solutions of silver nitrate to 
persistently ulcerated areas may be made through a Kelly cystoscope. 
Many methods of treatment have been suggested for the relief of tuber- 
culous cystitis, but none of these is satisfactory unless the focus of infection 
in the kidney is eliminated. Many of the advanced cases never recover 
completely, and in some local treatment appears to aggravate rather than 
relieve the condition (see pages in and 473). 

VESICAL CALCULUS 

The surgeon is less often called upon to treat vesical calculus in women 
than in men, for the reason that the female urethra is short and that the 
stone is discharged while it is still small, and before it gives rise to symptoms. 

Etiology. — The calculus may be the result of the agglutination of pre- 
cipitated urinary salts, but often a foreign body of some sort serves as a 
nucleus about which the concretion is formed. Such a foreign body mav 
have been introduced through the urethra, e.g., the end of a catheter, a 
hair-pin, etc. Small papillomatous vegetations of the bladder mucosa, non- 
absorbable sutures introduced in the course of an operation through the 
mucosa, etc., may also form the nucleus of a vesical calculus. 

Symptoms. — The symptoms are those of chronic cystitis, with which 
stones of any size are always complicated, plus an obstruction to the urinary 
outflow, manifested by a sudden cessation of the stream during the act 
of micturition. 

Diagnosis. — Cystoscopy examination will at once reveal the presence of 
a vesical calculus if it lies free in the bladder, but if the stone lies within a 
diverticulum, it may easily be overlooked by the cystoscopist. When the 
calculus is of considerable size and free, a metal sound or a searcher intro- 
duced while the bladder is full, will elicit the characteristic feel of a hard 
body within and a clinking sound audible upon suprapubic auscultation. 
Large stones may often be felt upon making bimanual palpation. In strongly 
suspected cases, if the methods just outlined have failed to reveal a calculus, 
the Rontgen ray should be used. 

According to Henry Pancoast : " The Rontgen examination for vesical 
calculus is also to be regarded as a most reliable means of diagnosis. The 
sources of error are somewhat greater than in calculus in the kidney or 
ureter, especially since uric-acid stones are more common. Occasionallv 
very large uric-acid stones may cast no perceptible shadow in perfectly 
satisfactory rontgenograms. Soft phosphatic stones may also escape detec- 



DISEASES OF THE BLADDER 459 

tion, especially in stout individuals and in those with thick bladder-walls. 
Large phleboliths, calcified lymph-glands, and fecal concretions are the 
usual objects whose shadows may cause confusion. The examination is 
valuable in detecting encysted stones that might readily escape discovery 
by the cystoscope or searcher. The Rontgen examination may be regarded 
as an efficient and reliable means of determining the presence, shape, and 
size of a vesical calculus, if it is borne in mind that negative findings do not 
always exclude stone." 

" Diverticula in the bladder may be detected by injections of the opaque 
solutions used in pyelography — collargol, thorium nitrate, or sodium bromide." 

Treatment. — The treatment of vesical calculus in females is simple. 
Stones of almost any size may be removed through an anterior vaginal in- 
cision. If the vaginal introitus is small, the suprapubic extraperitoneal route 
may be the preferable one. If the mucous membrane of the bladder is ex- 
tensively ulcerated, continuous drainage should be provided for a time. 
This may be accomplished by the formation of a vesicovaginal fistula, but 
in most cases a self-retaining catheter will be sufficient. In any event, the 
treatment for chronic cystitis, which is always present, should be carried out. 

HUNNER TYPE OF BLADDER ULCER IN WOMEN 

Hunner describes a type of ulcer observed by him in twenty-five women, 
which differs in several ways from the solitary ulcer of Fenwick. There is no ap- 
parent cause for the ulcer, and the average age at which it appears is twenty 
years. It is always found on the summit, or free portion of the bladder, in contra- 
distinction to the ulcer of Fenwick, which is found in the fixed portion or base of 
the bladder. The history is one of insidious onset, without apparent cause, and 
persistence in spite of various forms of treatment. All the cases have exhibited 
symptoms of chronic urethritis and some of them, remote foci of infection. 
The most characteristic feature is the insignificance of the lesion as com- 
pared with the prolonged duration and the intensity of the patient's suffer- 
ing. Slight, smooth, white scars of former ulcerations, as well as moderate 
hypersemia or inflammatory spots near the scars may be present. In other 
cases there is a small area of granulation that bleeds because of the disten- 
tion of the bladder, or will bleed easily on being touched. The inflamma- 
tory spot may be surrounded by oedema. Macroscopically the urine from 
such a case appears normal, but under the microscope the centrifuged speci- 
men will show a few leucocytes and red blood corpuscles. The diagnosis 
depends mainly on the resistance of the ulcer to the ordinary forms of treat- 
ment. The proper treatment of these cases consists in excising the ulcer 
through a suprapubic incision, operating extraperitoneally. (See Hunner's 
papers for further details.) 

NEW GROWTHS OF THE BLADDER 

Tumors of the bladder arise from the mucosa (epithelial) or the mus- 
cularis (connective tissue). The epithelial new growths, especially papil- 
loma and carcinoma, are the most frequent, but cystoma and adenoma are 
also encountered. The connective-tissue neoplasms are myxoma, fibroma, 
sarcoma, myoma, and angioma. Dermoid tumor, rhabdomyoma, and chon- 
droma constitute the mixed varieties. 



460 GYNECOLOGY 

Vesical tumors are more frequent in men than in women. Two-thirds 
of all bladder tumors are malignant. 

Papilloma. — This is the most frequently observed vesical tumor seen in 
women. While some papillomata are benign, a large majority are malig- 
nant, and all should be regarded as malignant until proved otherwise by 
microscopic examination. Their most common seat is the base of the blad- 
der. Papillomata are made up of branching papillae ; they are composed of a 
connective-tissue framework with a covering of epithelium made up of 
many layers. The growth may be pedunculate or sessile, and vary in size 
from a pinhead to an egg. They may be single, are often multiple, and rarely 
may be so numerous as almost entirely to fill the bladder. 

Carcinoma. — Carcinoma of the bladder may be of papillary or of infiltrating 
form. In the early stage papillary carcinoma may be indistinguishable from 
benign papilloma except on microscopic examination. Infiltrating carcinoma 
penetrates the connective tissue of the bladder wall, forming flat, indurated nodes 
with ulceration of the superficial areas within the bladder. 

Symptoms. — The commonest symptom of bladder tumor is hematuria. 
To this may be added difficulty in emptying the bladder or a sudden cessa- 
tion of the stream, depending upon the relation of the new growth to the 
internal urinary meatus. In a large number of instances cystitis supervenes, 
and then urination becomes frequent and painful. Later, if ulceration or 
necrosis of the new growth takes place, there may be toxaemia, loss of 
w r eight, fever, etc. 

The urine at first contains blood, the amount of which gradually in- 
creases as the case advances ; pus, bacteria, and broken-down particles of 
the new growth are added later. The urine is alkaline and foul smelling, 
except when there is no retention. 

Diagnosis. — The diagnosis of bladder tumor is dependent on cystoscopic 
examination. Papillomata with a well-defined, narrow pedicle are less 
prone to be malignant than are those with a broad, base. An irregular, 
bossed, infiltrated, and ulcerating surface must be looked upon as malig- 
nant until it is proved otherwise. 

The histologic examination of portions of the tumor excised or snared 
off by the cystoscopist may show certain evidences of malignancy ; these 
have been described by Buerger. The objections to this plan are the pro- 
duction of hemorrhage and the danger of implanting small portions of the 
growth in other parts of the bladder. Probably the best method is to base 
the diagnosis on the cystoscopic appearance (narrow pedicle, without infil- 
tration of the base in benign papillomata ; broad pedicle or sessile tumors 
with infiltration of the bladder wall in malignant papillomata, etc.). If 
electrocauterization of a papilloma adjudged to be benign is not quickly fol- 
lowed by destruction and disappearance of the growth, malignancy should 
be suspected. 

Treatment. — Benign papillomata should be treated by electrocauteriza- 
tion. When the pedicle is narrow, it should be the special object of attack, 
for if this is destroyed, the tumor will drop off. In sessile growths the 
application should be made all over the periphery of the tumor, so as to 
destroy as much as possible at one sitting. For the narrow-pedicled villous 



DISEASES OF THE BLADDER 461 

type of papilloma the Oudin current is preferable, because it sears over and 
destroys the delicate villi, with little or no consequent bleeding. The fibrous 
root of such and of all papillomata with broader pedicles requires the 
stronger D'Arsonval current. When marked hemorrhage takes place at 
each attempt at fulguration, or if the growth is inaccessible or the patient is 
intolerant, as well as in cases of papillomatosis, usually the result of mul- 
tiple implantations following a previous operation, this method of treat- 
ment is impracticable. In these cases cystotomy should be performed and 
the tumors attacked directly with a cautery. 

Malignant papillomata should be treated by electrocauterization plus 
radium. 

Geraghty used 103.7 m g m - of radium in practically all his cases. A brass 
capsule was employed, so as to use both the gamma and the beta rays. The 
radium was applied directly to the growth, under full cystoscopic exposure. 
The seances usually consumed an hour, and were repeated from one to three 
times weekly. 

Papillary carcinoma of the bladder is not amenable either to electro- 
cauterization or to radium, unless the growth is exposed by a suprapubic 
incision (see Chapter XL). 

If the growth is not too large, radical excision should be done, with 
transplantation of the ureter. 

Excision of bladder growths should be performed, whenever practicable, 
through an extraperitoneal incision. The bladder should previously have 
been rendered as sterile as possible by antiseptic irrigation. A transverse 
suprapubic incision gives the best exposure. The viscus should be distended 
with air to facilitate orientation. The neighboring cellular tissue and mar- 
gin of the incision should be protected by gauze pads. 

Single pedunculated tumors should be surrounded with gauze, the 
pedicle crushed with forceps, and divided with the cautery knife. When 
the growth is sessile, an attempt should be made to evert the area of the 
bladder, which is the seat of the growth through the vesical incision. The 
diseased part should then be excised together with a portion of the sur- 
rounding healthy area. When it is evident that the growth is malignant, 
the entire thickness of the bladder wall should be taken, the line of excision 
being made at a considerable distance from the infiltrated margins. 

When a ureteral orifice lies directly in the path of excision, the ureter 
should be catheterized, dissected free, and the diseased part excised, and the 
healthy extremity reimplanted in an uninvolved area. 

BIBLIOGRAPHY 
Beer, Edwin : " The Surgical Therapy of Benign and Malignant Tumors of the Urinary 

Bladder." J. A. M. A., 1917, lxviii, 680. 
Buerger, Leo. : " The Pathological Diagnosis of Tumors of the Bladder, with Particular 

Reference to Papilloma and Carcinoma." S., G. and O., 1915, No. 2, xxi, 179. 
Casper : " Zur Pathologie u. Therapie der Blasentuberculose." Monats. f . Urologie, 1900, 

Bd. v, S. 499. 
Dudley : " Incontinence of Urine in Women." J. A. M. A., June 3, 1905. 
Geraghty, J. T. : " Fulguration in the Treatment of Bladder Tumors." S., G. and O., 1915, 

No. 2, xxi, 150; Ibid. : "The Results of Treatment of Bladder Tumors." J. A. M. A., 

1917, lxix, 1336; Ibid.: "Treatment of Bladder Tumors." N. Y. Med. Jour., 1916, 

civ, 838. 



462 GYNECOLOGY 

Hunner, G. L. : " Ureterovesical Anastomosis — An Improved Method ; Report of Two 
Cases." Amer. Gynecology, December, 1902; 'Ibid.: "A Rare type of Bladder Ulcer 
in Women; Report of Cases," Boston Med. and Sur. Jour., 1915, clxxii, 660: Ibid. : 
" Elusive Ulcer of the Bladder. Further Notes on a Rare Type of Bladder Ulcer, 
with a Report of Twenty-five Cases." Trans. Am. Gyn. Soc, 1918, xliii, 27-63. 

Keene and Laird : " The Diagnosis of Tuberculosis of the Kidney." Amer. Jour. Med. 
Sci., September, 1913, No. 3.. 

Meyer, W. : " Early Diagnosis and Early Nephrectomy for Tuberculosis of the Kidney." 
Med. News, May 1, 1897. 

Rovsing, T. : Die Blasenentzundungen, ihre Aetiologie, Pathogenese, und Behandlung. 
Berlin, 1900. 

Uhle and MacKinney : " High-Frequency Destruction of Tumors of the Bladder." 
Penna. Med. Jour., March, 1916, 423. 



CHAPTER XXIV 
URINARY FISTULA 

The most common site of a urinary fistula is between the bladder and 
the vagina; this is known as a vesicovaginal fistula (Fig. 404). Fistulous 
communication may take place between other parts, such as the urethra 
and the vagina (urethrovaginal) (Fig. 405), the bladder and the cervix 
(vesicocervical) (Fig. 406), and between the ureter and the vagina (uretero- 
vaginal (Figs. 408 and 409). 

Etiology. — Fistulse involving the urinary tract may be produced in sev- 
eral ways. Probably the most common cause of fistula is necrosis following 
dystocia, in which a part of the urinary apparatus has been caught between 




Fig. 404. — Vesicovaginal fistula— result Fig. 405. — Urethrovaginal fistula; — result of 

of trauma of labor or operation. trauma of labor or operation. 

the fcetal head and the unyielding pelvic bones, and so compressed that 
necrosis of the affected part has subsequently occurred. The most common 
fistula due to this cause is the vesicovaginal. 

Fistula may be the result of injury to the bladder or ureters after cer- 
tain operative procedures, such as panhysterectomy for carcinoma. Opera- 
tions for the cure of cystocele or uterine prolapse, as well as certain surgical 
obstetric procedures, such as vaginal Csesarean section or pubiotomy, may 
occasionally be causative factors. Fistulse also occur in cases of advanced 
carcinoma of the cervix, or as the result of syphilitic or tuberculous ulcera- 
tion, or of ulceration produced by a foreign body, such as a pessary. 

Symptoms. — A urinary fistula following a difficult labor usually mani- 
fests itself at some time during the puerperium, being preceded by febrile 

463 



464 



GYNECOLOGY 



disturbance, vaginal discharge, and hematuria. The early symptoms are 
due to a necrosis of the devitalized tissue, and when the slough has separated, 
the incontinence becomes manifest. Ureteral fistulse following hysterec- 
tomy usually make their appearance within two to three weeks after operation. 
The urinary incontinence of vesical fistula varies in degree with the size 




Fig. 406. — Vesicocervical fistula — result of 

trauma of labor, operation or carcinomatous 

ulceration. 



Fig. 407. — Rectovaginal fistula — result of 

trauma of labor, operation or syphilitic 

ulceration. 






Fig. 408 




Fig. 409 




Figs. 408 and 409. — Ureterovaginal fistula — result of trauma of labor or operation. 



and the site of the fistula and with the posture of the patient. The incon- 
tinence of a ureteral fistula is constant and not dependent on the position of 
the patient. The dribbling from a vesical fistula may be constant if the 
fistulous opening is large and if it is situated at the trigone ; or it may be 
apparent only after distention of the bladder has taken place, or, when 
the fistulous opening is small and the opening is high up near the cervix, 
only in the reclining posture. 



URINARY FISTULA 465 

As a result of the incontinence there is maceration of the tissues 
about the fistulous opening, and a deposit of urinary salts upon the vaginal 
walls and the external genitalia. There may also be excoriation of the 
external genitalia and of the inner surface of the thighs. Beneath the in- 
crustation of urinary salts ulceration of the mucous membrane may take 
place. The urine often undergoes ammoniacal decomposition and gives off 
a foul odor. Emaciation, depression of spirits, and general ill health 
may occur. 

Ureteral fistulae are less likely persistently to discharge urine in consid- 
erable amount than are vesical fistulae. As a rule, the dribbling of urine 
gradually grows less, and sooner or later it is markedly diminished, either 
from spontaneous closure or because there is sufficient contraction of the 
fistulous opening to obstruct the ureter, reduce the excretory activity of the 
affected kidney, and produce a hydronephrosis. About 50 per cent, of post- 
operative ureteral fistulae close spontaneously in from four to six weeks. In 
most of those that do not close spontaneously, stenosis of the ureter, hydro- 
nephrosis, pyelitis, and pyelonephritis take place. It is also usually evi- 
dent that the site of the fistula is the ureter, owing to the fact that the 
bladder becomes filled with normal urine from the uninjured ureter, and is 
emptied at regular intervals, whereas in the case of vesical fistulae very little 
or no urine may be passed through the urethra. 

Diagnosis. — The diagnosis of a urinary fistula can usually be formulated 
from the symptoms, although a functional incontinence of urine may be 
mistaken by the patient for the evidence of a fistula. Examination is impor- 
tant chiefly for determining the exact site and position of the fistula ; this is 
not always easy. The difficulty in locating the position may be due to sev- 
eral causes. If the laceration or necrosis of tissue that produced the fistula 
is extensive, there may be considerable scar tissue in the vagina or about 
the vaginal vault, making exposure of the parts difficult. 

The incrustations of urinary salts and the tenderness incident to a low- 
grade inflammation of the mucous membrane may render any manipulation 
painful and difficult. In simple cases the fistulous opening may be located 
by means of a probe introduced through the vagina or the bladder. The 
site of the fistula may also be indicated by filling the bladder with a colored 
solution, such as methylene-blue, or with sterile milk, and exposing the 
anterior vaginal wall to view. The exact position of the vesical fistula and 
the condition of the bladder mucosa may also be ascertained by cystoscopic 
examination, the patient being placed of necessity in the Sims' or the knee- 
chest position in order to secure atmospheric distention. 

In cases of ureteral fistula that do not involve the vesical part of the 
ureter, the fluid injected into the bladder will not escape, and the urinary 
excretion from the sound side, obtained by catheterizing the bladder, may 
show no abnormal constituent. 

In cases of ureteral fistula cystoscopic examination will show the in- 
terior of the bladder to be uninvolved ; inspection of the orifice of the 
affected ureter will fail to disclose the periodic retraction and discharge of 
urine, and a catheter introduced into the affected ureter will usually meet 
with obstruction before it has passed very far. As a rule, it is possible to 
30 



466 GYNECOLOGY 

pass a ureteral catheter through the vaginal opening of the fistula into the 
affected ureter, and possibly into the pelvis of the corresponding kidney. 
This, combined with an obstruction close to the bladder in the vesical part, 
will be sufficient ground on which to base the diagnosis. 

Treatment. — The treatment of vesical fistula is usually operative. In 
early cases, when the fistulous opening is small, a spontaneous cure may be 
looked for and encouraged by draining the bladder with a self-retaining 
catheter, and touching the edges of the fistulous opening with silver nitrate. 
Most cases, however, will require some form of operative procedure. In 
these the patient should be prepared for operation by treatment directed to 
rendering the operative area as nearly normal and free from infection as 
possible. To this end the patient should be instructed to drink water 
freely. The diet should be bland, and a urinary antiseptic should be pre- 
scribed. For this purpose a combination of sodium benzoate and hexa- 
methylenamine, 5 grains of each four times a day, will usually be satisfac- 
tory. The incrustations may be removed with warm alkaline solutions, and 
the irritated mucous membranes touched with silver nitrate and protected 
with a thick ointment. After this preparatory treatment, which will suc- 
ceed in removing urinary incrustations and in relieving inflammation of the 
vesical mucous membrane and of the vaginal mucosa, an operation for 
closure of the fistula may be undertaken. The success and ease of perform- 
ance of the operation will depend upon the size and the position of the 
fistulous opening and upon its accessibility. 

The typical operation for vesicovaginal fistula consists of making a 
boat-shaped denudation about the fistulous opening, upon the anterior 
vaginal wall, the margins of the denudation sloping from the vagina toward 
the bladder. The denuded area is then approximated by means of 
sutures that are passed down to, but that do not include, the vesical 
mucous membrane. It is usually preferable to make the denudation in the 
long axis of the vagina, so that the sutures may be passed and tied in a 
transverse direction, thus causing less traction upon the cervix, and lessen- 
ing the tendency to shorten the anterior vaginal wall. The direction of the 
denudation will, however, depend somewhat upon the conditions of the indi- 
vidual case, and, as a general rule, the denudation should be made in that 
position in which coaptation of the denuded margins will cause the 
least traction. 

Fistulous openings high in the vagina, and especially those following 
hysterectomy, may be difficult to expose and to treat in the manner just de- 
scribed. In such cases it will be advisable, as advocated by Ward, to free 
the bladder wall, as far as possible, from its surrounding attachments to 
the broad ligament, the cervical stump, or the vaginal fornix ; draw it into 
the incision, and prepare the vesical opening separately from the 
vaginal opening. 

The vaginal wall is divided by a longitudinal incision that passes directly 
through the fistulous opening and extends for an equal distance in front of 
and in back of that point. If the incision alone does not permit of sufficient 
mobilization of the bladder, a second transverse incision, bisecting the first 
at the fistulous opening, is made. 

In closing the fistula the vesical and the vaginal sutures should pref- 



URINARY FISTULA 



467 



erably be placed in different sagittal planes, i.e., they should not be in apposi- 
tion (Fig. 410). When the vesical injury is close to the ureteral area, so 
that in passing the sutures there is danger of injuring or obstructing the 
vesical portion of the ureter, it will be advantageous at times to make an 
incision into the bladder, of sufficient length to expose the ureteral orifices, 
and then to place catheters in these orifices while the sutures are 
being passed. 

Ureterovaginal fistula may be treated by operation from below (vaginal), 
operation from above (extraperitoneal laparotomy), or by removal of the 
affected kidney. 




Fig. 410. — General scheme of operation in vesicovaginal fistula: 1, incision to one side of fistulous 
opening; 2, excision of vaginal wall about fistulous orifice; 3, denudation of fistulous opening in the 
bladder wall and separation of vaginal flaps from bladder wall; 4, parts denuded, ready for suture; 
5, scheme of suture of bladder opening; 6, bladder opening sutured; 7, suture of vaginal incision com- 
pleted and relation of suture line to suture line of the vesical orifice. 

I. Vaginal Operation. — The vaginal route is applicable to fistulae situ- 
ated near the bladder. The vaginal mucosa is divided over a line that cor- 
responds to the position of the ureter within the bladder wall. The vaginal 
wall is then separated, on each side of the incision, from the bladder and the 
ureter, a catheter is inserted into the fistulous opening, and the lower end 
of the upper segment of the ureter is dissected free. The freed lower end 
is turned into a small opening made in the bladder wall at an adjacent con- 
venient point, and anchored with sutures, the butt-end of the catheter having 
previously been passed into the bladder through the anastomotic opening 
and brought out through the urethra. The divided vaginal mucosa is now 
brought together over the operative area and secured with separate sutures. 
The ureteral catheter should be left in situ for two or three days. 



468 GYNECOLOGY 

2. Extraperitoneal Abdominal Operation. — In this method an incision is 
made in the semilunar line, directly over the pelvis. The peritoneum is 
pushed up, and the lower end of the upper ureteral segment is gently freed. 
An anastomosis with the bladder is now made, the guide to the vesical open- 
ing being a pair of closed forceps introduced into the bladder through the 
urethra. The ureteral end, which has been slit bilaterally for a short dis- 
tance, is now drawn into the bladder and fixed to the vesical wall with catgut 
sutures. The muscular wall of the bladder is then united to the ureteral 
wall with fine linen sutures. The bladder itself is drawn up and attached to 
the ureter above the anastomosis, so that it partly envelops the lower ex- 
tremity of the ureter. The downward pull of the bladder should be relieved 
by releasing the lateral attachments of the bladder and by suturing the 
organ to the pelvic wall at some convenient point. The wound should be 
closed with drainage, but great care must be taken that the drain does not 
come in contact with the area operated on. 

Uretero-ureteral anastomosis is not so satisfactory as ureterovesical 
anastomosis, but in some cases the former may appear to be desirable. In 
performing this operation the end of the distal ureter is divided in the 
median line for a distance of half a centimeter. This slightly increases the 
circumference of the distal opening. The proximal end is now drawn into 
the distal opening, well beyond its margins, and fixed in position by a trac- 
tion suture of catgut. The operation is completed by inserting interrupted 
sutures of catgut uniting the outer walls of the proximal and distal seg- 
ments at their junction. 

Ureterorectal or sigmoidal anastomosis, after the method of Stiles, may 
be performed as follows: The proximal end of the ureter is implanted into 
the lowest part of the pelvic colon by traction sutures of catgut that include 
all the coats of both intestine and ureter. Permanent fixation of the ureter 
to the intestine is now made by uniting two parallel folds of the intestinal 
wall over the implanted ureter, from a point three-fourths of an inch below 
the anastomotic site to one inch above it. For this purpose fine linen sutures 
are used. 

Nephrectomy is the operation of choice when either of the operations 
just described promises to be especially difficult or has been unsuccessful, 
and when the opposite kidney is healthy and able to carry on the renal 
function. Nephrectomy is indicated also when there is evidence of hydro- 
nephrosis or pyelonephritis on the affected side, and when the opposite 
kidney is healthy. 

BIBLIOGRAPHY 

Emmett: Vesicovaginal Fistula, etc. New York, 1868. 

Kelly : " The Treatment of Vesicovaginal and Rectovaginal Fistulse High up in the 

Vagina." J. H. H. Bulletin, igo2, vol. xiii. 
Lamballe, Jobert de: Traite des Fistules Vesico-Uterines, Vesico-Utero-Vaginales, etc. 

Paris, 1852. 
Simon : tiber die Heilung der Blasenscheiden-Fisteln. Giessen, 1854. 
Sims, J. M. : " On the Treatment of Vesicovaginal Fistula." Amer. Jour. Med. Sci., 

1852, xxiii, 59. 
Stiles, H. J. : " Epispadias in the Female, and Its Surgical Treatment." Surg., Gynec. 

and Obst., 191 1, xiii, 127. 
Ward, G. G. : " The Operative Treatment of Inaccessible Vesicovaginal Fistulae." S., G. 

and O., 1917, No. 2, xxv, 126. 



CHAPTER XXV 
DISEASES OF THE KIDNEY AND URETER 

The diseases of the kidney that are of particular interest to the gyne- 
cologist are ptosis, hydronephrosis, pyelonephritis, tuberculosis, calculus, 
and tumor. 

ptosis (abnormally movable kidney) 

Etiology and Pathology. — The kidney is considered to be abnor- 
mally movable when it can be brought entirely below the costal mar- 
gin. Ptosis is seen in about 25 per cent, of women. 1 Movable kidney is 
favored by congenital defects in the kidney fascia and the kidney fossse, 
and by the diminution of intra-abdominal pressure incident to relaxation of 
the abdominal wall following pregnancy. Ptosis may also be produced by 
the wearing of improper corsets, with constriction at the waist, and pos- 
sibly, under predisposing conditions, by trauma. Movable kidney is often 
found in thin women with long waists, who manifest a tendency to a gen- 
eral ptosis of the abdominal viscera ; in these cases the renal fascia is poorly 
developed and the kidney fossa is shallow. 

Symptoms. — An abnormally movable kidney may give rise to no symptoms. 
When symptoms are present, they are occasioned by kinking of the ureter, torsion 
of the renal vessels, and traction upon the duodenum. Acute attacks of 
pain (Dietl's crisis) may occur when the ureter is kinked as the result of 
obstruction of the ureteral lumen and distention of the renal pelvis by the 
urine that is dammed up behind the seat of obstruction. Intense congestion 
of the entire kidney, caused by torsion and obstruction of the renal vessels 
in the kidney pedicle, may also give rise to acute attacks of pain. The less 
severe symptoms of abnormal mobility are : A sensation of weight or of 
dragging after prolonged standing or walking; digestive disturbances, due 
to traction of the displaced kidney upon the intestine. 

Diagnosis. — The diagnosis of movable kidney is easily made. The directions 
for palpation of the kidney have been given elsewhere (page 138). By conjoint 
manipulation the kidney can readily be palpated, its shape and size noted, its ready 
displacement upward beneath the margin of the ribs observed, as well as a 
return to its former location when the examiner's hands no longer support it. 

Movable kidney does not call for treatment so long as it is not giving 
rise to positive and actual symptoms. When attacks of kidney colic occur, 
there is usually a kink of the ureter, and this can be demonstrated, if deemed 
desirable, by pyelography, the picture being taken with the patient in the 
erect or nearly erect posture. When the movable kidney is believed to be 
the cause of digestive disturbances or of a dragging or heavy sensation upon 
standing or walking, the actual part of the kidney in the production of these 

1 The right kidney is more frequently abnormally movable than the left ; both kidneys 
are more often movable than the left kidney alone ; in but 7.5 per cent, of cases of abnor- 
mally movable kidney is the left side only involved. 

469 



470 GYNECOLOGY 

symptoms may be ascertained by supporting the organ with a pad. Great 
care should, however, be taken to differentiate symptoms actually due to 
the kidney itself from those resulting from a general tendency to visceroptosis. 
Treatment. — The treatment of nephroptosis consists in the wearing of a suit- 
able corset or pad or in operative procedure. A well-constructed corset with a 
pad so placed as to exert pressure on the abdominal wall beneath the kidney area 
may result in relief of symptoms, and if the patient takes on fat, may be 
curative. As a rule, abnormally movable kidneys that give rise to repeated 
acute attacks of pain require the operation of nephropexy for their relief. 

HYDRONEPHROSIS 

Etiology and Pathology. — Hydronephrosis, or the accumulation of urine in 
the pelvis of the kidney, may be congenital or acquired. The immediate cause 
of the congenital variety may be complete or partial stricture of the ureter; 
malformations of the ureterovesical or the ureteropelvic junction ; kinks or 
twists in the course of the ureter ; a too oblique or too high insertion of the 
ureter into the kidney pelvis ; kinking of the ureter over anomalous kidney 
vessels ; congenital displacement or congenital tumors of the ureter, blad- 
der, or adjacent organs. 

The acquired form of hydronephrosis may be the result of trauma to the 
kidney pelvis or the ureter, with subsequent displacement, adhesions, dis- 
tortion, or cicatricial contraction. Compression of the ureter by pelvic 
tumors or infiltrations, stricture of the ureter following inflammatory lesions, 
renal or ureteral calculi, in short, any form of obstruction that develops 
slowly but continuously may produce a hydronephrosis. 

The most common form of hydronephrosis seen in women is that which 
is intimately related to floating kidney. Pyelitis also may lead to hydro- 
nephrosis, for when the mucous membrane of the ureter and kidney pelvis 
becomes swollen, a tendency to valve formation frequently develops, the 
mucosa of the kidney pelvis becoming displaced downward and invaginating 
itself into the narrow ureteral orifice. As the hydronephrosis develops and 
the resulting cyst becomes larger, the kidney pelvis becomes so distorted as 
further to increase the obstruction to the outflow of urine through the 
ureter. After distention of the kidney pelvis has reached a certain stage the 
calyces of the kidney begin to distend, and finally the medulla and the cortex 
are thinned and stretched, and the kidney takes on the form of an irregular 
cystic tumor in whose walls may be found the remnants of the original 
kidney tissue. 

Symptoms. — Up to a certain point in the development of hydronephrosis 
the accumulation of urine is intermittent, being interrupted by periods of 
relief ; that is, the patient will suffer at repeated intervals from attacks of 
renal colic, followed by an increased discharge of urine as the pain subsides. 
Between the attacks the symptoms may be nil, or there may be a feeling of 
constant distress, fullness, tension, or soreness on the affected side. In 
severe cases, during the period of distention, a well-marked enlargement 
may readily be detected in the kidney region. If, however, the examination 
is made at a time when the distention has been relieved and the walls of the 
hydronephrotic sac are flaccid, no enlargement may be apparent on palpa- 



DISEASES OF THE KIDNEY AND URETER 471 

tion. It is in these cases that pyelography proves a very valuable aid to 
diagnosis. If the ureter of the affected side is catheterized and the pelvis 
injected with sodium bromide, thorium nitrate, or collargol, the outline of 
the kidney may be determined with absolute certainty. These patients 
usually take a large amount of the injection fluid before complaining of 
pain, as much as 30 to 40 c.c. being injected in some cases. 

Diagnosis. — The differential diagnosis between hydronephrosis, cystic dis- 
tention of the gall-bladder, and cystic tumors of the ovary and intestine has been 
much simplified by pyelography. The enlarged mass also will present the char- 
acteristic features of kidney enlargements. (See pages 135 and 138.) 

Treatment. — In the early stage the treatment consists in removing the 
source of the obstruction. When the case is advanced and the kidney 
parenchyma is atrophied, extirpation may be considered if the opposite 
kidney is healthy and is already bearing the bulk of the excretory function. 
Removal of the obstruction may require various procedures and operations, 
such as excision of pelvic tumors, dilatation of a constricted ureter, removal 
of ureteral calculi, suspension of a ptosed kidney, etc. Local treatment of 
pyelitis and plastic operations for the removal of valve-like formations in 
the kidney pelvis and the ureter may also be required. When the kidney 
substance itself forms part of the wall of the hydronephrotic sac, or if the 
distention of the kidney pelvis itself has reached such a degree that there is a 
valve-like formation between the kidney pelvis and the ureter, a nephrectomy 
is often advisable. Plastic operations on the kidney pelvis designed to cor- 
rect abnormal relations between the kidney pelvis and the ureter, although 
occasionally brilliant successes, in the majority of cases simply put off the 
day when nephrectomy must be performed. 

PYELONEPHRITIS, PYELONEPHROSIS, EMPYEMA OF THE KIDNEY PELVIS, AND 

KIDNEY ABSCESS 

Etiology and Pathology. — Infections may reach the kidney through the 
blood, by way of the urinary passages, or from neighboring organs. Recent ob- 
servations have shown that the haematogenous form of infection is the most fre- 
quent. Hematogenous infection is possible whenever bacteriaemia is pres- 
ent, and occurs in such diseases as pneumonia, typhoid fever, diphtheria, 
osteomyelitis, puerperal sepsis, erysipelas, phlegmons, furuncles, infected 
wounds, etc. The streptococcus is the organism most often concerned in 
this form of infection, but the staphylococcus, the gonococcus, the pneumo- 
coccus, and the bacillus typhosus may also cause haematogenous infection 
of the kidney. Infection from the urinary passages occurs usually by exten- 
sion from the bladder along the mucous membrane of the ureter, or through 
the peri-ureteral lymphatics to the kidney pelvis ; it may also be carried 
through the lymphatics and the veins from various septic areas along the 
course of the ureter. In ascending infections the colon bacillus plays a very 
prominent part, and the proteus vulgaris is not infrequently found. The 
gonococcus is not, as a rule, a source of infection of the upper urinary pas- 
sages. Its chief role undoubtedly consists in the alterations it produces in 
the lower urinary passages, notably stricture and partial obstruction of the 
urinary outflow. The stagnation of urine favors the development and 



472 GYNECOLOGY 

growth of other organisms. All kidney infections are aggravated by ob- 
struction to the excretion of urine. 

Cabot and Crabtree assert that the coccal infections of the kidney affect 
the cortical portion and produce the lesions that have generally been re- 
garded as indicative of a haematogenous infection ; the colon-typhoid group 
of organisms, on the other hand, produce their changes in the kidney pelvis 
and neighboring tubules — the lesions generally regarded as significant of an 
ascending infection. 

The diseases of neighboring organs that may extend to the kidney are 
appendicitis, caries of the vertebrae, and abscess of the liver or the spleen. 

Hsematogenous pyelonephritis may affect both sides. In the severest 
forms death may occur before many alterations take place in the kidney. 
Marked hemorrhages may occur throughout the kidney, or minute ab- 
scesses may develop. Finally, the entire kidney may be honeycombed with 
abscesses, the pus eventually finding its way into the kidney pelvis, and 
resulting in pyelitis and obstruction of the ureter. The streptococcus and 
the staphylococcus, or other so-called pus cocci, are usually the infecting 
agents. In the form due to the colon bacillus, and generally regarded as 
secondary to infection of the bladder and ureter, ureteritis and pyelitis are 
the first symptoms observed, followed by involvement of the medullary part 
of the kidney. The path of the infection is shown by red stripes running 
from the pelvis to the capsule, along which rows of abscesses quickly de- 
velop. Many cases of so-called ascending infection are in reality instances 
of haematogenous infection with the colon bacillus. 

Stagnation of the urine and dilatation of the kidney pelvis increase the 
urinary tension within the kidney and favor the coalescence of abscess 
cavities with one another and with the kidney pelvis, so that finally the 
organ becomes transformed into a large abscess sac, with but very little 
kidney tissue remaining. 

Symptoms. — The symptoms of an acute haematogenous suppuration (usu- 
ally streptococcus, staphylococcus, or pus cocci) may be entirely general, with no 
indications pointing to localized infection. This is true in those cases that 
rapidly prove fatal. When the infection is less virulent, there may be acute 
pain in the loins, with scanty or no urine. The urinary findings that are 
most suggestive are granular casts, blood, and albumin. Bacteria will be 
found only in the earlier stages, and pus is not found, as a rule. In the 
earlier stages the phthalein test is negative or nearly so. The kidney region 
may be sensitive from the first, but no demonstrable enlargement may be 
manifest until later. The early general symptoms are those indicative of 
sepsis elsewhere, such as high temperature, chills, etc. Later, when suppu- 
ration is established, the fever becomes remittent, and as the case progresses 
uraemia supervenes. Leucocytosis is present throughout the infection, vary- 
ing in accordance with the severity and the resistance of the individual. 

The symptoms of colon-bacillus haematogenous infections of the kidney 
and of the ascending forms of pyelonephritis are less sudden in onset and in 
general less serious. Usually a history of previous lesion in the lower 
tract may be elicited. Whatever the nature of this previous illness was, it 
must have been followed by some obstruction in the ureter, bladder, or 






DISEASES OF THE KIDNEY AND URETER 473 

urethra. Often a bacteriuria has existed for some time, the patient having 
observed that the urine has a disagreeable odor. Ascending pyelonephritis 
may be precipitated by instrumentation. Pain develops along the course of 
the ureter of the affected side, gradually extends to the loin, and becomes 
more severe and constant. As the disease progresses fever, leucocytosis, 
enlargement and tenderness of the kidney, and anaemia develop, and bacteria 
and pus are present in the urine, which is very often alkaline. The phthalein 
test shows a diminution of function. The pain increases periodically, and 
is followed by a profuse discharge of pus from the ureter, after which the 
symptoms subside until pus reaccumulates within the kidney. 

Treatment. — The treatment varies with the severity of the affection. In 
the severest form dry cups and ice may be used in the early stage. As a rule, 
as soon as the organ becomes palpably enlarged and the evidences of sup- 
puration are definitely established, nephrotomy should be performed and 
drainage established. The general condition should receive treatment at 
the same time, and an effort should be made to remove the primary 
focus of infection. 

In the milder (colon-bacillus), so-called ascending form, when only one 
kidney is involved, the indications are to relieve any obstruction that may 
be present in the lower part of the urinary tract, and, second, to increase 
the amount of urine secreted and render it as bland as possible. With these 
points in mind, a stone blocking the ureter, a stricture, or a violent cystitis 
should be exposed to active treatment, and urinary antiseptics and 
diluents prescribed. 

When the symptoms point to a beginning suppurative lesion of the 
kidney substance itself, immediate operation should be advised. After ex- 
posing the kidney, if it seems probable that the infection is confined entirely 
to the pelvis, its posterior wall should be incised and the edges sutured to 
the border of the lumbar wound, so as to provide sufficient drainage. If 
the suppuration has extended to the medulla or to the cortex of the kidney, 
a nephrotomy incision should be made along Brodel's white line, and the 
pelvis and calyces exposed to examination. If the kidney is destroyed en- 
tirely or nearly so, and the other kidney is in good condition, nephrectomy 
should be performed. 

TUBERCULOSIS OF THE KIDNEY 

Etiology and Pathology. — Tuberculosis of the kidney is almost invari- 
ably secondary to tuberculosis elsewhere in the body. In a considerable 
proportion of cases, however, the primary focus cannot be demonstrated 
clinically. One case of tuberculosis of the kidney in which, at autopsy, no 
other tuberculous lesion could be found anywhere in the body, has been 
reported by Stewart and Kelly. Tuberculosis of the kidney may occur as a 
part of an acute miliary tubercular process, in which case it is usually 
bilateral, and occurs most frequently in children. This form of infection is 
of no surgical interest, and need not be considered here. The form of tuber- 
culosis of the kidney or tuberculous disease of the kidney which is amenable 
to surgical treatment is known as the caseocavernous variety. With few 
exceptions the route of infection is through the blood. Extension from 



474 



GYNECOLOGY 



neighboring tuberculous foci has been reported, and an ascending form of 
infection from the bladder has also been encountered. Trauma to or any 
disease that lowers the resistance of the kidney may predispose the organ 
to tubercular infection. 

Although it may occur in early life, caseocavernous tuberculosis of the 
kidney is usually encountered in adults, the average age being thirty-two 
and a half years. The disease is generally unilateral at first, and remains so 
for a long time, especially in those patients who are not suffering from 




Fig. 411. — Tuberculosis of the kidney, upper half diseased. First symptoms four years 
before removal. (Stetson Hospital). 

active tuberculous lesions elsewhere. According to Israel, with whom Kelly 
agrees, 90 per cent, of the cases that reach the surgeon are unilateral. 

The disease usually begins in the glomeruli, near the medulla, where 
tubercles, surrounded by marked round-cell infiltration, make their appear- 
ance. A number of these areas may coalesce, forming nodules that undergo 
caseation and softening in the center, and appear as grayish-white or 
yellowish-gray masses. These may remain discrete and scattered 
throughout the cortex and medulla, or a number of them may coalesce, 
forming cavities of greater or lesser size (Fig. 411). With this cavity 
formation there may be degeneration of the neighboring parenchymatous 
kidney cells, and the substitution of fibrous tissue. If the pelvis of the 






DISEASES OF THE KIDNEY AND URETER 475 

kidney has not been invaded and the ureter is patulous, the kidney may not 
be enlarged. The organ is usually irregularly lobulated, some of the lobule? 
being hard, and others soft. 

Sooner or later some of the caseous cavities open into the kidney pelvis 
and involvement of the ureter then takes place. This is manifested by the 
formation of tubercles in the mucosa, with caseation and ulceration, and 
marked infiltration and thickening of the muscular wall. Stricture of the 
ureter may result, or the lumen may become plugged with caseous matter. 
Obstruction of the ureter may lead to an increase in the kidney lesion, with 
the formation of larger cavities and destruction of the remaining parenchyma. 
If secondary infection occurs, the process may be intensified, suppuration 
may take place, and the kidney be transformed into a huge multilocular 
abscess sac. Perirenal abscess is especially likely to follow secondary infection. 

Symptoms. — As a rule, the earliest manifestation is increased frequency 
of urination. This may occur even before any recognizable changes in the 
bladder or ureteral orifice take place, which may be explained on the ground 
of a reflex pain or an irritating toxin in the urine. When, later, the bladder 
is involved, there is increased ferquency of urination, the desire to urinate 
becomes intense and even uncontrollable, and the act is associated with 
pain. The severity of the bladder symptoms corresponds in the main to the 
extent of the vesical involvement, but many exceptions occur. Increased 
frequency of urination without recognizable pelvic lesions, without altera- 
tions in the bladder that are detectable by the cystoscope, and with no abnor- 
mal constituent in the urine, is always at least suggestive of early renal 
tuberculosis. Sooner or later pus and blood make their appearance in the 
urine, varying in amount according to the location of the kidney lesion and 
the patency of the ureter. The attention of the patient is drawn to the 
urinary abnormality by turbidity in the case of pus, or by the change in color 
in the case of blood. 

If the tuberculous focus does not communicate with the kidney pelvis or 
the ureter is blocked there may be little pus. The amount of pus may sud- 
denly increase if a focus bursts into the pelvis or a ureteral obstruction is 
removed. Haematuria is most pronounced when the tuberculous focus 
affects principally the papillae. 

The first symptom of renal tuberculosis may consist of haematuria or an 
attack of renal colic. In two-thirds of the cases there is a certain amount of 
distress in the kidney; usually this is merely a fairly constant feeling of 
pressure or a dull ache, but occasionally there are paroxysmal attacks of 
renal colic. The colic is due either to inflammatory swelling of the mucosa 
of the ureter obstructing the urinary outflow, or to the attempted passage 
of tuberculous detritus, blood-clots, etc. 

In the later stages, when pyonephrosis or perirenal abscess is present, 
the local pain and tenderness are usually well marked and unmistakable. 

The general symptoms of renal tuberculosis, like all the others, depend 
on the exact location and extent of the disease and the associated conditions. 
In early or moderately advanced cases there may be no more than a slight 
evening rise of temperature, with malaise and anaemia. In advanced cases, 
when the ureter is blocked and pyonephrosis or perinephritis or both are 



476 GYNECOLOGY 

present, there may be high fever, exhausting sweats, and rapid emaciation. 
Between these two extremes there are many variations. So long as there is 
no secondary infection, leucocytosis is usually absent. 

In the early stages the kidney is, as a rule, slightly enlarged, but this 
enlargement can be recognized by palpation in less than half of the cases. 
It is more frequently recognized when the right kidney is affected than 
when the left is the seat of disease. If the ureter is blocked and there is 
more than the usual increase in size, or if secondary infection and pyone- 
phrosis or perinephritis are present, the kidney is generally palpably en- 
larged. There is often some tenderness in the costovertebral angle, especially if 
perinephritis is present. It must be remembered that the unaffected kidney may 
be larger than the diseased organ, owing to compensatory hypertrophy. 

The urine usually contains pus and blood, the amount varying accord- 
ing to the location of the tuberculous foci, the patency of the ureter, and the 
vesical alterations. The pus from a tuberculous kidney is grayish and 
granular, and gives to the urine a ground-glass appearance in contrast to the 
soft, yellowish appearance given by the pus in other conditions (Keene 
and Laird). 

The reaction of the urine is persistently acid. In the absence of mixed 
infection no bacteria may be found by smear or culture. Tubercle bacilli 
may be found in the urinary sediment by staining, but they cannot be abso- 
lutely differentiated from the other acid-fast organisms by microscopic ex- 
amination. The presence of tubercle bacilli in the urine must be confirmed 
by animal inoculation (see page in). 

The tuberculous ureter may be tender along its entire course, but the 
enlargement is usually difficult to demonstrate, except in its lower part, 
where it passes through the parametrium at its point of entrance into the 
bladder. Upon simple digital examination per vaginam the affected ureter 
may be felt as a tender, rigid cord, about the thickness of a lead-pencil, 
running from the trigone outward under the vaginal wall, to the side of the 
cervix, where it is lost in the broad ligament. By bimanual palpation with 
one finger in the rectum the course of the ureter may be followed out to the 
pelvic wall. Any abnormality may be emphasized by comparing it with the 
ureter of the opposite side. Pressure upon the ureter often gives rise to an 
intense desire to urinate. 

The cystoscopic examination is possibly the most important of any 
single method of diagnosing tuberculosis of the kidney. The cystoscopic 
findings have been described under the head of Tuberculous Cystitis, page 457. 

Diagnosis. — The diagnosis of renal tuberculosis should be based on the 
results of a combined clinical and laboratory examination. Cystoscopic ex- 
amination is the most valuable single diagnostic aid, and in a majority of 
cases forms the basis from which conclusions are to be drawn. The appear- 
ance of the bladder may be more or less characteristic. The ureteral orifices 
may at once indicate the particular kidney affected. It now remains only to 
catheterize the suspected side and collect a specimen for guinea-pig inocula- 
tion. If the laboratory examination yields a positive result, an injection of 
indigo-carmine should be given in order to determine the relative activity of 
the two kidneys. The phenolsulphonephthalein test should also be em- 



DISEASES OF THE KIDNEY AND URETER 477 

ployed to determine the total renal efficiency. Catheterization of the appar- 
ently normal side should be avoided if the diseased kidney is failing to 
excrete and the indigo-carmine and phenolsulphonephthalein tests indicate 
that the other organ is maintaining alone a normal renal excretory function. 
Otherwise a catheter may be passed a few centimeters into the ureter of the 
sound side, in order to exclude, so far as possible, any involvement. 

Enlargement and tenderness of the lower part of the ureter are not 
diagnostic of tuberculosis, and may be found in ureteral stone or in stricture 
at the lower end of the ureter with ureteritis. 

A single negative laboratory result, no matter how thoroughly the exami- 
nation was conducted, does not determine an absolutely negative diagnosis 
of renal tuberculosis, as the manifestations of this disease are essentially 
intermittent. Negative results obtained in three successive weekly exami- 
nations should, however, have considerable bearing on the diagnosis (Keene 
and Laird). 

Treatment. — A tuberculous kidney should be removed by nephrectomy 
if the opposite organ is functionally able to meet the increased demands that 
will be made upon it. That this kidney is in good condition is evident when 
the diseased side excretes no indigo-carmine, when a dark-blue cloud is 
ejected from the opposite ureter a few minutes after an intramuscular injec- 
tion of the coloring matter has been made, and when the total phenolsul- 
phonephthalein output is normal. These findings indicate that the diseased 
kidney is functionally incompetent, and that its fellow is doing all the 
work. Under these circumstances the diseased kidney may be removed with 
the assurance that the remaining organ has already taken over and will 
continue to carry on the renal function. When the diseased kidney is still 
excreting, a careful relative estimate should be made of the amount of work 
each organ is doing. The indigo-carmine may appear on the diseased side 
much later, and the intensity of the blue color be much lower, than on the 
healthy side ; if, together with such a rinding, the phthalein test is normal, 
one may be sure that the opposite kidney is functionally competent. 

When desirable, each kidney may be tested separately by the phenolsul- 
phonephthalein test : As large a ureteral catheter as can be introduced is 
laid into each ureter, and the injection is made directly into a vein; the 
urine, as it drops from the ends of the catheters, is received in separate 
tubes. The time required for excretion is estimated for each side and then 
the total amount excreted is measured. 

It is often impracticable to continue this test for more than thirty 
minutes, and in some cases even less, so that a comparison of the two sides 
for the usual duration of the phthalein test cannot be made. But if the 
total phthalein output and the quickness of the reaction are previously 
known, a comparison of the two sides, even for two periods of fifteen 
minutes each, will yield valuable information as to the relative activity of 
the two kidneys. When tuberculosis of the kidneys is bilateral, operation 
is contraindicated except in the rarest instances, as, for example, when fever 
is continuous and is due to a mixed infection in the kidney most involved; 
when the bladder is being severely irritated by the discharge into it of large 
quantities of pus from the most affected side ; when the more involved side 



478 GYNECOLOGY 

is so extensively diseased that its removal will have no effect on the renal 
function (Zuckerkandl) ; or when, although both kidneys are involved, the 
disease in one is of recent origin and the less involved organ is capable of 
bearing the entire burden of urinary excretion. 

When nephrectomy for tuberculosis is undertaken in the early stage of 
the disease, no unusual difficulties are encountered. Later, when the peri- 
nephritic fat has been affected or the kidney is much increased in size or 
adherent to neighboring structures, the operation may be attended 
by difficulties. 

Certain points in connection with the operation are worth keeping in 
mind : First, sufficient exposure must be obtained, either by division or 
excision of the twelfth rib, or by an anterior transverse incision at right 
angles to the loin incision — about its middle — the so-called frying-pan in- 
cision ; second, thorough mobilization of the kidney must be effected before 
ligating the pedicle; third, double ligation of the pedicle in sections should 
be performed, preparing the vessels separately, if possible, by dissection of 
the fat ; fourth, the ureter should be divided as low down as practicable with- 
out unduly prolonging or increasing the dangers of the operation. 

In large pyonephrotic tuberculous kidneys intracapsular nephrectomy is 
the procedure of choice. This is performed by cutting directly through the 
capsule and enucleating the kidney from within outwards ; occasionally in 
advanced cases it may come away in pieces. As the separation proceeds 
and the kidney substance is drawn out of its bed, the pedicle is brought into 
view and secured with clamps. After the kidney is cut away the pedicle is 
ligated with catgut. 

Removal of the entire ureter is unnecessary, nor should one go to any 
great amount of trouble to secure a large part of it. As was shown by 
W. J. Mayo, the only tuberculous ureters that require removal are those in 
which there is a stricture close to the bladder, which causes more or less 
retention. In other cases the injection into the ureter of from five to ten 
minims of 95 per cent, phenol, with secure ligation, is the most 
satisfactory procedure. 

Prognosis. — In the early stage of the disease, when the process is limited 
to one kidney, permanent recovery may confidently be expected. If there is 
extensive involvement of the bladder, the primary mortality may reach 5 
per cent, and the later mortality 20 per cent. About 60 per cent, are perma- 
nently cured, whereas in the remainder abnormal urine and other symptoms 
persist. The prognosis is better in women than in men. 

RENAL CALCULUS 

Etiology and Pathology. — Renal calculus occurs most frequently in those 
between the ages of twenty and fifty. Predisposing factors are a very rich diet, 
composed largely of nitrogenous food, and the consumption of minimum amounts 
of water in the dietary. It is directly produced by precipitation of the urinary 
salts. This precipitation may collect upon foreign bodies in the kidney 
pelvis, such as a bit of mucus, a shred of necrotic epithelium, detached par- 
ticles of a new growth, or tuberculous detritus. After the nucleus has been 
formed the stone increases in size by successive deposits of urinary salts 



DISEASES OF THE KIDNEY AND URETER 479 

upon its surface. Kidney stones may be composed of uric acid, urates, 
oxalates, or phosphates. The configuration of kidney calculi is dependent 
upon their position and number ; at first they are small and oval, but as they 
increase in size they gradually take the form of the part in which they lie. 
A large calculus may fill the entire pelvis of the kidney, being branched like 
a piece of coral, and fitting closely into the calyces. A stone overlying the 
ureteral orifice may be tunneled, or have a groove on one side, through 
which the urine gains entrance to the ureter. Kidney calculi are 
often bilateral. 

Symptoms. — The symptoms of kidney calculus are pain in the affected kid- 
ney or lower abdominal quadrant, increased by movement, by jolting, and by 
pressure. If the stone becomes so displaced that it blocks the ureter, renal colic 
ensues. This consists of a violent paroxysmal pain, radiating along the course of 
the ureter to the genitalia and the inner surface of the thighs. The suffering in 
some cases is extreme, so that the patient presents all the appearances of 
severe shock or collapse. Nausea, retching, and vomiting are common. 
There is marked vesical tenesmus, the patient straining even after the 
bladder is emptied, and voiding a few drops of dark-colored or even bloody 
urine. The abdominal muscles on the affected side are rigid, and the patient 
assumes various positions in an effort to find one that is comfortable. The 
attack may last from one to two hours to as many days. It may end as 
suddenly as it began. Relief is experienced as soon as the obstruction is 
overcome by the stone passing through the ureter into the bladder, or being 
displaced from the mouth of the ureter into some other part of the kidney 
pelvis, or by the urine finding its way around the stone. Renal colic is not 
peculiar to kidney stone, being nothing more than an indication 
of great tension within the kidney ; it is occasioned also by twisting of the 
vessels at the hilus or obstruction of the ureter from any cause whatever. 
The urine in kidney calculus usually contains blood, at times in micro- 
scopic amounts only. The amount of blood usually varies from time to 
time, being more profuse after riding, active exercise, etc. Long and narrow 
hyaline casts, albumin, and high specific gravity are generally found. If the 
outflow of urine on the diseased side is completely blocked, nothing abnor- 
mal may appear in the urine. The kidney may become infected second- 
arily, under which conditions the symptoms of a pyelonephritis are added 
to those of the kidney stone. 

Diagnosis. — The diagnosis of renal calculus is made from a consideration of 
the symptoms plus a Rontgen-ray examination. The latter should be made after 
suitable preparation of the patient, i.e., thorough evacuation of the intestinal 
tract with castor oil. Pills should not be taken by the patient for several 
days before examination. Correct interpretation of the skiagraph is impor- 
tant, as shadows believed to be the result of calculi may be due to calcified 
lymph-glands, gas, pills or tablets, fecal concretions, especially in the appen- 
dix, collections of pus in the kidneys, phleboliths in the pelvic veins, and 
sesamoids in the tendons arising from the spine of the ischium. In order 
to confirm the diagnosis of renal calculus two or more Rontgen-ray pictures taken 
at different times should agree. Stones in the ureter may be differentiated 
from stones outside by a picture taken after catheterization of the ureter 
with a shadow (bismuth) catheter or by a stereoscopic picture. 



480 GYNECOLOGY 

Treatment. — The treatment of kidney stone depends upon its size and posi- 
tion. If it is small, lies near the pelvis of the kidney, and is not giving rise to acute 
distress, it may be left undisturbed in the hope that it will be expelled spon- 
taneously. The patient should be directed to drink an abundance of water 
containing as little saline matter as possible (distilled water), and the diet 
should be restricted in quantity and in its nitrogenous element. During an 
attack of renal colic the pain should be relieved by a hypodermic injection 
of morphine and atropin and the local application of heat. In cases in which 
the symptoms are active and the stone is of considerable size or in such a posi- 
tion that spontaneous cure cannot be expected, operation should be per- 
formed at once. The kidney should be exposed, pyelotomy or nephrotomy 
should be done, and the stone extracted. If the case is clean, the kidney 
wound may be sutured and drainage omitted. If the kidney is markedly 
diseased, and it has been determined that the opposite kidney is perfectly 
healthy and has been assuming the bulk of the renal function, nephrectomy 
may be done, but the frequency of bilateral involvement in cases of kidney 
stone must be remembered, and nephrotomy with drainage relied upon, un- 
less it can be demonstrated that the affected organ is useless and its fellow 
kidney in good condition. 

TUMORS OF THE KIDNEY 

Tumors of the kidney are not very frequent. The most common variety 
is hypernephroma. Other forms are papillary cystoma, endothelioma, sar- 
coma, carcinoma, and adenoma. 

The symptoms are hematuria, pain, and enlargement of the kidney. 
Haematuria is the most common early symptom, and occurs with or without 
renal colic. In women the growths very often escape observation until the tumor 
is of considerable size, and when operation is unlikely to prove curative. Al- 
though renal colic does not always occur, there may be a disagreeable sense of 
pressure in the loin on the affected side. The urine may have the color of 
fresh blood, and may vary from almost pure blood to a straw-colored serum, 
or it may be clear and contain coagula. Worm-like clots, 10 cm. long, are 
significant of coagulation within the ureter. Casts and albumin usually 
appear sooner or later. Palpation of the kidney may show a smooth, sym- 
metric enlargement of the entire organ, or a nodular enlargement project- 
ing from the anterior surface of the lower pole. 

A positive diagnosis at times cannot be arrived at without an exploratory 
incision. A kidney tumor must be differentiated principally from tuber- 
culosis and renal calculus. This can usually be accomplished by the methods 
of diagnosis already given for these two conditions. As soon as the diag- 
nosis is made nephrectomy is indicated, provided the opposite kidney 
is healthy. 

Cystic Tumors of the Kidney. — Cystic tumors springing from the outer 
region of the cortex and bordered by the compressed parenchyma may be 
found associated with contracted kidney. The symptoms are those of 
nephritis, pressure, and tumor. Partial nephrectomy is the operation 
of choice. 

Polycystic Disease of the Kidney. — Polycystic disease of the kidney may 



DISEASES OF THE KIDNEY AND URETER 481 

be present at birth or appear later in life. In its external appearance the 
kidney may resemble a bunch of grapes. 

The symptoms vary, but usually there are polyuria, intense thirst, slight 
oedema, and later uraemic indications, combined with the development of a 
palpable tumor in one or both kidney regions. 

The diagnostic points are the frequency of bilateral involvement, the 
knobbv surface and the deficient elimination from each kidney. 

The treatment should be medical, and not operative, unless it can be 
determined absolutely that the disease is unilateral and that the unaffected 
kidney is functionally competent. 

Adenocystoma. — Adenocystoma may be benign or malignant. The 
benign form resembles the early stage of polycystic disease of the kidney 
and requires the same treatment. The malignant form presents the same 
general features of other malignant renal growths. The differential diag- 
nosis can be made only as the result of an exploratory incision. 

Echinococcus Cysts. — The kidney is said to be affected in from 5 to 8 
per cent, of all cases of hydatid disease. Urinary constituents on which to 
base a diagnosis are found only when the cyst is evacuated into the kidney 
pelvis. When this occurs, booklets and daughter cysts may be found in 
the urine. 

The treatment consists in incision and suture of the sac wall to the lumbar 
wound. If the situation of the cyst is favorable, resection may be done. 

Adrenal Tumors. — Adrenal tumors are exceedingly malignant and can- 
not be differentiated from kidney tumors except by making an 
exploratory incision. 

Pararenal Tumors. — Pararenal tumors differ from those of the kidney 
in that they are not associated with alterations of the urine. The prognosis 
is unfavorable. Operative removal is difficult, but unless this is done they 
almost invariably prove fatal. 

OPERATIVE TECHXIC 

Incision. — The kidney may be exposed by various incisions, the choice 
of which depends upon the operation that is to be performed. For nephro- 
pexy, for decapsulation of the kidney, for nephrotomy, and for many nephrec- 
tomies an incision running from the twelfth rib to the crest of the ilium. 
along the outer margin of the erector spinae, is the most suitable. The fibers 
of the latissimus dorsi are divided close to its point of coalescence with the 
fascia of the erector spinae. but without opening the sheath of the latter. 
The fibers of the quadratus lumborum muscle are bluntly separated along 
their course without cutting, or the muscle may preferably be displaced in- 
ward. The ileohypogastric nerve is sought for in front of and along the 
outer margin of the quadratus, and turned to one side. The transversalis 
fascia is divided, exposing the perirenal fat. which is caught with artery 
forceps and divided well to the inner and posterior part of the wound, in 
order to avoid the colon. The separation of the perirenal fat is completed 
by means of the finger, until the kidney is felt and seen in the depths of the 
wound. Instead of making a vertical incision, it may be made slightly 
oblique, running downward and outward toward the anterior-superior spine. 
31 



482 



GYNECOLOGY 



A muscle-splitting incision, which can be increased to almost any 
extent, is begun to the inner side of the anterior superior spine of the ilium, 
and is carried backward obliquely toward the tip of the last rib. The fibers 
of the external oblique and its aponeurosis are separated and retracted, ex- 
posing the internal oblique muscle, the muscular fibers of which are split on 
a line between the ninth costal cartilage and the posterior superior spine of 
the ilium, in which position they are longer than in front of or behind that 
line. The fibers of the transversus are split and retracted along with the 
oblique muscle. A diamond-shaped space is thus formed, at the bottom of 
which the transverse fascia is seen; this is incised, exposing the perirenal 
fat, and on pushing through the fat, the kidney is easily reached, whatever 
the position it may occupy. This incision gives ample room, and, if neces- 
sary, the whole hand may be introduced into the circumrenal space. If it 
becomes necessary to expose the ureter, the incision may be continued ob- 




Fig. 412. — Suspension of the kidney by Edebohl's technic. The capsule of the 

kidney has been reflected and the suspension sutures introduced. (Kelly and 

Noble's Gynecology and Abdominal Surgery.) 

liquely downward toward Poupart's ligament. The internal oblique will 
then require suturing in order to bring the divided ends together. Pref- 
erably a second lower incision through the outer border of the rectus muscle 
may be made to reach the ureter. 

Whether a vertical, an oblique, or a muscle-splitting incision is used, the 
muscle-fibers should be separated, rather than divided, as far as possible; 
the ileohypogastric nerve should be located and pushed to one side, and the 
transversalis fascia should be opened close to the spinal margin of the 
wound, in order to avoid the peritoneum. After exposing the kidney the 
organ may be delivered by hooking the finger under the lower pole and 
lifting it out of the wound by making gentle traction on the fatty capsule. 

If it is found that extirpation of the kidney and the ureter is absolutely 
necessary, the parts may be exposed by an oblique incision beginning at the 
junction of the erector spinae with the twelfth rib, running forward and 
downward to a point two or three fingerbreadths to the median side of the 
anterior superior spine or che ilium. An incision in this direction has the 



DISEASES OF THE KIDNEY AND URETER 



483 



advantage of exposing the upper segment of the ureter. The incision may 
be lengthened downward, on a line parallel with Poupart's ligament. 

When the kidney enlargement is extreme, forming an abdominal tumor, 
a transperitoneal incision may be made. This incision runs along the outer 
border of the rectus muscle of the affected side, its midpoint corresponding 
to about the center of the kidney mass. The peritoneum is opened, and the 
kidney exposed by incising the outer layer of the mesocolon (see 
Chapter XXXVI). 

Nephropexy. — After the kidney has been delivered, the convex border is 
freed from fat, the capsule proper is nicked over the dorsum of the kidney, a 
grooved director is thrust between the capsule and the kidney substance, 
and the former is divided in a straight line from one 
pole to the other. The capsule is now stripped on 
both sides half way to the hilum, and sutures are 
passed through the capsule at four points, pucker- 
ing the capsule at the point of suture as indicated (Fig. 
412). When the capsule has been secured at four 
points on both surfaces, the kidney is replaced, and 
the fatty capsule is disposed principally about the 
lower pole, where it is sutured with fine catgut to 
the surrounding tissues. The sutures that were pre- 
viously introduced through the capsule are then 
passed through the fibers of the quadratus muscle, 
bringing the raw surface of the kidney directly in 
apposition with the surfaces of that muscle. The 
wound is then closed with interrupted sutures of 
silkworm gut that embrace the entire depth of the 
wound, care being taken to avoid inclusion of the 
ileohypogastric nerve. 

Nephrotomy. — After exposure and delivery the 
kidney and accessible part of the ureter should be 
carefully palpated. On account of the great ad- 
vancement that has been made in skiagraphv of the FlG - 413— Bloodless nephrot- 

o r ^ omy incision; immediately pos- 

kidnev and pyelography, nephrotomv is becoming- terior to the outer convex 

. J . . r " x f , r 1 ' - border. (Kellv and Noble's 

ieSS and leSS necessary. In doubtful Cases, however, Gynecology and Abdominal 

in which stone, beginning tumor, or early tuberculosis is urger -' 
suspected, the kidney may be split by an incision through Brodel's white 
line. The technic of this procedure is indicated in the accompanying illus- 
tration (Fig. 413). If the kidney is not infected and no further operative 
treatment is required, the wound may be closed by through-and-through 
sutures of catgut introduced by means of a blunt needle. If the kidney is 
infected, a small drainage-tube may be introduced. 

Nephrolithotomy and Pyelotomy. — For these operations the kidney is 
exposed and delivered in the usual way. The incision for the removal of the 
stone depends upon the position of the latter. A single stone in the cortex 
may be remo\~ed by making a simple incision directly over it. If the stones 
lying entirely in the kidney pelvis are small, they may be removed by mak- 
ing an incision through the pelvis that does not involve the kidney sub- 




484 



GYNECOLOGY 



stance. In some cases complete hemisection of the kidney will facilitate the 
operation and lessen the danger of leaving stones behind. The incision 
should be made along Brodel's white line. The upper end of the ureter 
should be palpated rather than sounded for stone, since sounding may cause 
impaction. In some cases it may be necessary to crush a stone before re- 
moval. As a rule, however, they may be removed by the finger, a scoop, a 
curette, or a pair of slender forceps. Flushing the kidney with a stream of 
normal salt solution under some pressure is especially valuable when the 
stone has been fractured, or numerous small stones are present. If the case 
is clean, and there has been little bruising, the kidney wound may be closed 



trigonvm 




Fig. 414. — Resection of last rib in nephrectomy. (After Cullen, from Kelly 
and Noble's Gynecology and Abdominal Surgery, W. B. Saunders Co.) 

with sutures. Incisions into the renal pelvis should be closed with fine 
sutures of catgut, comprising only the outer surface. If the case is infected, 
or the kidney is much damaged, drainage must be employed. 

Nephrectomy. — Nephrectomy is performed as follows : After exposure 
of the kidney in the usual way, it is freed from the surrounding tissues and 
delivered through the incision. The separation from the surrounding tissues 
should be continued until the renal artery and vein, as well as the pelvis and 
ureter, are isolated. A ligature should be passed around the vessels of the 
pedicle and tied separately, without including the ureter. After the vessels 
have been divided the ureter should be separated as far down as necessary 



DISEASES OF THE KIDNEY AND URETER 485 

and divided between two ligatures, the exposed mucous membrane of the 
lower end being carefully disinfected with phenol and alcohol. If the 
kidney is very large, some difficulty may be experienced in effecting 
its delivery. 

A cystic kidney may be reduced in size by aspiration. Deliv- 
ery of the kidney is sometimes facilitated by introducing the fingers be- 
neath the lower ribs, and forcibly pulling them up ; at other times division of 
the twelfth rib near its vertebral articulation or resection of the twelfth 
rib simplifies delivery (Fig. 414). If the transperitoneal route is selected 
for the removal of kidney tumors of large size, resection of the rib will not 
often be necessary, and exposure and delivery of the kidney will be rendered 
less difficult. 

PYELITIS 

Etiology and Pathology. — Pyelitis as seen by the gynecologist occurs as a 
complication of pregnancy or the puerperium, in the course of development of 
intrapelvic growths and after operations. It may appear suddenly in the form of 
acute attack, or slowly as a chronic condition. The latter may be the result of 
an acute pyelitis or of a moderate but progressive obstruction to the ureter, such 
as may be observed in prolapse of the uterus with a marked cystocele. As a 
rule, two causes are responsible for the occurrence of pyelitis : First, an ob- 
struction to the urinary outflow ; and secondly, an infection. De Lee asserts 
that 15 per cent, of pregnant women have bacteriuria. This fact, together 
with the pressure of the enlarging uterus and the distortion of the ureters 
incident to pregnancy, furnishes the reason for the comparative frequency 
with which the condition appears in pregnant women. According to De Lee, 
the normal pressure of urine in the kidney pelvis is only 10 mm. Hg, so that 
slight causes may impede or check the outflow. The ureters, moreover, par- 
ticularly the right, have been found dilated and filled with urine in about two- 
thirds of the pregnant women coming to autopsy. 

The infecting organism is usually the colon bacillus, but others, such as 
the tubercle bacillus, the bacillus proteus, the staphylococcus albus and 
aureus, the bacillus typhosus, the gonococcus, the streptococcus, etc., have 
been reported. The organisms reach the pelvis of the kidney and ureter 
through the kidney tubules, being excreted through the kidney (bacteriuria), 
through the blood-stream, or by way of the lymph-channels, from neigh- 
boring structures (appendix, colon), and by ascending from the bladder 
either along the mucosa, as was previously believed, or by floating from a 
lower to a higher level in a collection of stagnant urine in an obstructed 
ureter, or through the periureteral lymphatics to the subpelvic areolar 
tissue that surrounds the blood-vessels of the kidney as they enter the pelvis. 

Cabot and Crabtree have recently declared that the colon bacillus and 
the typhoid bacillus produce a different set of lesions in the kidney than do 
the streptococcus, staphylococcus, etc. 

The colon-typhoid group causes acute pyelitis, acute pyelonephritis, 
chronic pyelonephritis, and pyonephrosis, whereas the coccus group causes 
perinephritic abscess, capsular abscess, capsulitis, cortical abscess, septic 
infarct, and diffuse suppuration. A mixed infection will show lesions char- 
acteristic of both groups. 



486 GYNECOLOGY 

Acute pyelitis is more frequently associated with the rapidly growing 
tumor of pregnancy than with other pelvic tumors. Occasionally, how- 
ever, it develops suddenly during the course of the growth of a fibroid. 
Pyeloureteritis may also follow septic catheterization or an acute gonor- 
rhoeal or a post-operative cystitis. In pregnancy it may develop as early as 
the eighth week. Usually it occurs about the fifth month or later. 
Occasionally it is observed during the puerperium, when it may be mis- 
taken for septic infection. The right kidney is more frequently involved 
than the left. 

Chronic pyelitis is much less violent than acute pyelitis in its manifesta- 
tions. It results from gradually produced stasis of urine plus an infection. 
The latter is usually caused by the colon bacillus, less often by the gono- 
coccus and the tubercle bacillus. The infection may come from the kidney, 
from the bladder, from the neighboring parts, or through the blood-stream. 
The cause of the obstruction may be a dislocation downward of the uterus 
and bladder, a slowly growing tumor compressing or constricting the ureter 
(fibroid tumor, carcinoma), a ureteral calculus, or contraction of the ureter 
following operative trauma, etc. 

Symptoms. — Although symptoms such as frequent and painful urina- 
tion may precede the onset, acute pyelitis usually presents itself with chill, 
fever, and pain along the course of the ureter and in the back. Vesical 
tenesmus, pain on urination, and a diminution of the urinary output are also 
present. The temperature often reaches 104 to 105 F., the rise usually 
being preceded by a prolonged and exhausting chill. The kidney on the 
affected side is markedly tender, and enlargement may be perceptible. Ex- 
amination of the urine shows the presence of large numbers of pus-cells, 
epithelial cells, and albumin. The ureter can sometimes be palpated through 
the vagina as an enlarged and tender cord. 

In the course of several hours or days the subjective symptoms 
may abate, the temperature declines, the pain subsides, the urine is voided in 
larger quantities, and contains an increased amount of pus and albumin. All 
may then go well for from twenty-four to seventy-two hours, when the 
symptoms may suddenly reappear. 

The attacks follow one another at different intervals and with varying 
intensity. In the milder cases prostration may not be marked, but in the 
severer ones the patient becomes emaciated, and the face assumes a hectic 
appearance. At first, at least, but one kidney, and that the right, is usually 
involved, but after several days or a week there may be pain along the oppo- 
site ureter and indications of an extension of the disease in that direction. 

The presence of kidney involvement is indicated by the disproportionate 
increase of albumin as compared with the number of leucocytes in the urine. 
Casts will also appear if there is any extension of the inflammatory process 
to the kidney structure. 

Prognosis. — Acute pyelitis may yield rapidly to treatment, or it may 
prove exceedingly stubborn and resistant to all methods of treatment. The 
prognosis in general is favorable, i.e., recovery usually occurs in from two 
to eight weeks. Labor and the emptying of the uterus are, as a rule, fol- 
lowed by rapid disappearance of the symptoms. Pyelitis may manifest itself 



DISEASES OF THE KIDNEY AND URETER 487 

during the puerperium, constituting a form of puerperal sepsis. Acute 
pyelitis due to the pressure of pelvic tumors is cured by the removal or 
displacement of such growths, the pressure on the ureter being relieved. 
The prognosis in chronic pyelitis is dependent upon the nature of the infec- 
tion and the organic changes that have occurred, e.g., whether the infection 
is caused by the colon bacillus, on the one hand, or by the tubercle bacillus, 
on the other ; whether the obstruction can be overcome, the amount of 
dilatation of the ureter that is present, and the extent to which the kidney 
pelvis is distended. 

The prognosis in chronic pyelitis in cases of long standing and in those 
associated with recurring or permanent dilatation of the kidney pelvis and 
residual urine is less favorable (see Hydronephrosis, page 470). In such cases, 
when no more radical measures are practicable, local treatment should be em- 
ployed, even though nothing more than temporary improvement is to be 
expected. According to Geraghty, in these cases formaldehyde solutions, 
varying in strength from 1 : 5000 to 1 : 2000, seem more effectual than the 
silver preparations. 

Treatment. — The treatment of acute pyelitis complicating pregnancy is 
postural, general, medicinal, and local. The patient should be placed in the 
Sims' position, on the healthy side, the elevation of the hips being exag- 
gerated by means of a hard pillow. The knee-chest position should be 
assumed several times within the twenty-four hours. The bowels should be 
kept open. Vegetable soups, milk in any form, and buttermilk may be 
taken. Water should be drunk freely. Solids and meat broths are to be 
prohibited. A urinary antiseptic, such as hexamethylenamine (5 grains) 
with sodium benzoate (5 grains) should be administered every three hours. 
Salol, 5 grains every three hours, is often the most effectual urinary antiseptic. 

If this treatment does not alleviate the symptoms, the ureter of the af- 
fected side should be catheterized and the ureter and kidney pelvis irrigated 
with a boric acid or normal salt solution, followed by a 10 per cent, solution 
of argyrol. This has two objects: First, to relieve obstruction of the ureter 
and drain accumulated urine and pus; and secondly, to destroy or weaken the 
infecting organisms. This last may need to be repeated, or one thorough 
irrigation may be sufficient to mark the beginning of an improvement which 
is gradually followed by complete disappearance of the symptoms. If, in 
spite of every effort, the symptoms persist or even increase in violence, and 
the patient is almost constantly in pain, the anaemia increasing rapidly, and 
a typhoid-like condition making its appearance, labor should be induced 
without hesitation. Acute pyelitis occurring as a symptom of pelvic tumors 
should be treated in the same way as the acute pyelitis of pregnancy. When 
the acute symptoms have subsided, the patient should be subjected to opera- 
tion, in order to avoid a repetition of the attacks. If the symptoms persist 
in spite of rest in bed, urinary antiseptics, and irrigation, operation should 
be undertaken at once, nitrous oxide-oxygen-ether anaesthesia being employed. 

The treatment of chronic pyelitis is dependent upon the form of infec- 
tion and the nature and source of the obstruction. Tuberculous cases need not 
be discussed here further than to state that as soon as the diagnosis is made, 
nephrectomy should be undertaken, provided the other kidney is healthy. 



488 GYNECOLOGY 

The local treatment of other forms of chronic pyelitis comprises relief of 
the urinary stasis in the affected ureter if this exists, the use of antiseptic 
solutions, and the injection of vaccines. The measures taken to relieve the 
urinary stasis depend upon the nature of the obstruction to the ureter. If 
this is caused by external pressure on the ureter, as in pregnancy, postural 
treatment, in addition to ureteral catheterization, may be effectual. Tumors 
or inflammatory masses pressing upon the ureter must be removed. A 
ureteral stone will, of course, require appropriate . treatment, which is 
discussed elsewhere. 

Obstruction due to prolapse of the uterus and bladder may be temporarily 
relieved by wearing a pessary, or may be permanently cured by operation. 
Obstruction caused by infiltration of the broad ligament by carcinoma is 
usually irremediable. Obstruction of the ureter associated with ptosis of 
the kidney and kinking may be relieved by wearing a belt and a pad, or by 
means of the suspension operation. 

A narrowing of the ureteral lumen or stricture may be corrected by the 
passage of ureteral catheters or bougies (see Ureteral Stricture, page 495). 
Indeed, in some cases this, in addition to urinary antiseptics and diluents, 
seems to be all that is needed. In the majority of cases, however, lavage of 
the kidney pelvis with boric acid solution, aluminum acetate, 2 per cent., 
argyrol, 25 per cent., or silver nitrate, 1 : 1000 will prove of value and will 
hasten the cure. Silver nitrate irrigation should be followed by normal 
salt solution. 

In practising lavage of the kidney pelvis the affected ureter should be 
catheterized by means of a small catheter. It should be of such size relative 
to the diameter of the ureteral lumen that there will be abundant space for a 
return flow of the irrigating solution into the bladder, whence it should be 
conducted immediately by a self-retaining catheter. 

After introducing the ureteral catheter, a little time should be allowed 
for drainage of the kidney pelvis. The irrigating solution is then permitted 
to flow into the catheter by means of gravity, using a burette or funnel. On 
the average, about 75 c.c. of the combined irrigating solution may be used at 
one sitting. The treatment may be repeated at intervals of from three to 
four days to several weeks, depending upon the effect produced and the 
urgency of the symptoms. 

If the treatment is carefully carried out, no unfavorable reaction will 
result. The slight discomfort that immediately follows the procedure sub- 
sides in the course of a few hours. The patient should not be considered 
cured until repeated examinations of the urine show it to be free from pus- 
cells and bacteria. 

Although the use of vaccines in the treatment of chronic pyelitis has 
not been encouraging, so far as can be judged from the literature, good 
results unquestionably follow in some cases : it may be used either alone or in 
conjunction with other treatment. 

At the time of the first ureteral catheterization a culture should be taken 
of the urine and a vaccine made therefrom; autogenous vaccines are prefer- 
able to stock vaccine. 



DISEASES OE THE KIDXEY AXD URETER 489 

URETERITIS 

Inflammatory diseases of the ureter usually coexist with cystitis or 
pyelitis, or with both. Thus the ureter may become diseased from 
the descent of an infection from the kidney above, or the condition may 
be the result of the ascent of an infection from the bladder below. The 
three most common infections of the ureter correspond, therefore, to those 
most frequently encountered in the kidney and in the bladder. They are 
colon bacillus, tubercle bacillus, and gonococcus infections. Primary ureter- 
itis may follow the lodgement of a stone in the ureter, or it may be caused by 
trauma during operation. 

Symptoms. — Ureteritis secondary to pyelitis manifests no symptoms. 
for pyelitis is associated almost immediately with pain along the course of 
the ureter. The onset of pain radiating from the pubes to the lumbar region 
on one side during the course of cystitis may. however, indicate the begin- 
ning of a ureteritis secondary to cystitis. 

Diagnosis. — Inspection of the ureteral orifices and bimanual palpation of the 
ureter are the only reliable physical methods for determining the existence of 
ureteritis, but they may fail to confirm the diagnosis unless the ureter is 
seriously diseased. Changes in the ureteral orifice, such as marked infection. 
bullous oedema, dilatation and fixation {i.e., a lack of contractile power) are 
indicative of ureteritis. Palpation of the ureters in the anterior vaginal 
vault, from a point about one and one-half inches from the urethral orifice 
and a half inch on either side of the median line, outward and upward to- 
ward the bases of the broad ligaments, may reveal tender cords, the thick- 
ness of a lead-pencil. " passing in a flat curve with the concavity directed 
upward from the vaginal vault to the lateral wall of the pelvis." 

Treatment. — The treatment of ureteritis is the treatment of pyelitis 
(page 487). 

URETERAL CALCULUS 

Etiology and Pathology. — Stone in the ureter is secondary to renal calculus. 

i.e.. the stone has its origin in the kidney, but escapes from the calyces of 
pelvis and lodges in the ureter. It may be found at the ureteropelvic junc- 
tion, in the upper third of the ureter, at the brim of the pelvis, in the pelvis 
at the ureterovesical junction, or within the intramural portion of the ureter. 
In the series of cases reported by Braasch and Moore, one-fourth of the 
ureteral calculi were lodged at the ureteropelvic junction or in the upper 
third of the ureter : three-fourths were lodged in the lower third : of the 
latter more than half were in the pelvic portion of the ureter and less than 
one-third were lodged at the ureterovesical junction, while most of the 
remainder were found in the intramural part of the ureter. 

A calculus may move at intervals of a few hours, days, weeks, or months 
to a position further down the ureter. Such stones are often passed spontane- 
ously into the bladder, from which they are discharged with the urine. If a 
calculus lodges in the ureter, the mucous coat of the ureter at this point 
gradually undergoes pressure atrophy or necrosis : the wall of the ureter in 
the adjacent region becomes dilated, permitting the urine to pass around 
the stone. The amount of ureteral dilatation that takes place depends upon 



490 GYNECOLOGY 

the degree of the obstruction. In well-marked cases of long standing the 
entire ureter above the stone becomes dilated (hydroureter), and even the 
kidney pelvis (hydronephrosis) may be affected. If the obstruction to the 
ureter is complete or nearly so, hydronephrosis with atrophy of the kidney 
substance may follow within a comparatively short interval. The presence 
of a stone in the ureter predisposes to infection, and this occurs ultimately 
in a large majority of the cases. Ureteritis, pyelitis, pyonephrosis, and peri- 
renal abscess may occur as sequelae. 

Symptoms. — In cases of ureteral calculus it is usually possible to elicit a 
history of an acute attack of sharp pain in the loin or hypogastrium, radiat- 
ing toward the bladder, accompanied by vesical irritability and gross or 
microscopic hsematuria. The pain is due to an increase of intrarenal ten- 
sion, the result of the urinary obstruction. The pain recurs in paroxysms 
and increases in severity until the stone is passed, or until the accumulated 
urine succeeds in forcing its way past the stone. When the stone escapes 
from the ureter, the attack subsides suddenly, but when the excretion of 
urine is diminished by the intrapelvic tension or enough dilatation of the 
ureter in the vicinity of the stone occurs to permit passage of the urine 
around it, the attack subsides slowly. As a rule, the attacks are repeated 
from time to time until the stone is passed, or permanent changes take place 
in the ureter or kidney that markedly diminish the kidney excretion or over- 
come the obstruction to the urinary outflow. Although the severest pain is 
usually felt in the loin, it is sometimes referred to the upper abdominal 
quadrant, and occasionally to the region of the lower ureter. Vesical irri- 
tability is almost invariably present during the attacks of renal colic due to 
ureteral calculus. In nearly half of the cases the urine is bloody, but in a 
very few no blood may be visible even microscopically. In the intervals 
between attacks the patient may be perfectly well, or there may be a feeling 
of uneasiness or distress in the loin or along the course of the ureter, this 
being increased by riding or by active exercise. The urine may be free of red 
blood-cells, but, as a rule, they are present coincidentally with an aggrava- 
tion of localizing symptoms. Sooner or later infection takes place, bacteri- 
uria and pyuria make their appearance, and to the symptoms previously 
noted may be added those of pyelitis, pyonephrosis, etc. 

When the acute paroxysms of pain in ureteral calculus are referred prin- 
cipally to the area of the lower ureter, they may simulate appendicitis, tor- 
sion or tubal or ovarian tumors, or the pain of tubal abortion or rupture in 
ectopic pregnancy. 

Diagnosis. — Most important and most difficult in such cases is the dif- 
ferentiation of ureteral colic on the right side from appendicitis. The chief 
points of difference between them are found in the constituents of the urine, 
the white blood count, and the temperature. 

Although an inflamed appendix that has become adherent to the ureter 
may give rise to sufficiently marked ureteritis to result in the appearance of 
blood and pus in the urine (Hunner's cases), this is most unusual, so that a 
catheterized urine highly charged with oxalates or urates and containing 
blood-cells, with or without leucocytes, points strongly to the presence of a 
ureteral calculus. 

In uncomplicated cases of ureteral colic there is no elevation of tern- 



i 



DISEASES OF THE KIDNEY AND URETER 491 

perature. When the ureteral stone is complicated by infection, indubitable 
evidence of the condition is found in the urine (pyuria, bacteriuria, etc.). 
Elevation of temperature, therefore, with normal urine points to 
appendix involvement. 

Increase in the white blood-cells is not the rule in ureteral stone unless 
evidences of infection are present in the urine, but this increase is quite 
customary and almost invariably present in appendicitis (see page 106). 

There are other points of differentiation : For example, the pain of an 
appendicitis is usually most marked about McBurney's point, whereas in 
right ureteral colic, at the height of the paroxysms, the pain, even though 
most severe in the lower ureteral area, is nearly always present to some 
degree in the loin, and follows the course of the ureter. Bladder symptoms 
are almost invariably present in ureteral calculus, but are quite unusual 
in appendicitis. 

A positive diagnosis of ureteral calculus often demands cystoscopic ex- 
amination, ureteral catheterization, a rontgenogram, or pyelography. In some 
cases cystoscopic exposure of the ureteral orifice on the suspected side will 
reveal the presence of a stone projecting from or plugging the ureter. If the 
stone is higher up, it may be recognized as a point of obstruction to the 
passage of a ureteral catheter, either rendering difficult or absolutely pre- 
venting further introduction of the instrument. 

The Rontgen ray, as a rule, furnishes the most positive and reliable informa- 
tion. Before the picture is taken the bowels should be thoroughly moved with 
castor-oil. If, after one picture has been taken, the position of a shadow 
gives rise to doubt as to whether the stone is a ureteral calculus or a phle- 
bolith, the ureter should first be catheterized with a styletted or bismuth 
catheter, and then another picture taken. Stereoscopic rontgenograms are some- 
times required to determine whether a given shadow is due to the presence 
of an object within or just over the ureter. The limitations of the rontgenogram 
are shown by Israel's report of sixty operations for ureteral stone. In 
almost 12 per cent, the picture was negative in spite of the fact that a stone 
was present. 

In one case seen by Clark and Keene, the injection of the ureter with 
collargol prior to taking the rontgenogram greatly strengthened the shadow of a 
calculus that had previously not interrupted the rays to a marked degree. 
From this it may be seen that we have in pyelography a useful additional 
diagnostic measure. 

Kelly has advocated the passage of wax-tipped catheters into the sus- 
pected ureter, the presence of a stone being indicated by scratch-marks on 
the wax of the catheter. This procedure may be carried out in conjunction 
with his direct method of cystoscopy and catheterization of the ureters, or 
with the indirect cystoscopic examination in a water-distended bladder. 

" The technic which Geraghty and Hinman employ in the use of the wax- 
tipped catheter consists in passing the waxed end into the bladder; the butt end is 
threaded backward into a catheterizing cystoscope, which is then passed into the 
bladder over the catheter as a guide. At no time must the wax portion come in 
contact with the metal of the instrument. After the instrument is in the bladder 
the catheter is slowly withdrawn until the wax tip appears in the cysto- 



492 



GYNECOLOGY 



scopic field, when it should be carefully examined to preclude the possi- 
bility of its having been scratched by any of the previous maneuvers. After 
the examination the instrument is removed first and then the catheter. As 
a rule, scratches produced by the contact of a stone are very definite and 
unmistakable" (Clark, Prog. Med., 1916, p. 307). 

Treatment. — During an acute attack of ureteral colic the patient should 
be kept in bed, where she will unconsciously assume the most comfortable 
position, i.e., lie on the affected side with the knee strongly flexed on the 
abdomen. A vigorous purgative (castor-oil or epsom salts), supplemented, 
if need be, with a high enema, should be administered. Heat should be 
applied to the loin and to the lower anterior abdominal surface. If, in spite 
of these measures, the pain continues to be unbearable, hypodermic injec- 
tions of morphine and atropin should be given. These not only relieve pain, 
but also, by relaxing the ureteral muscles, apparently favor the passage of 
the calculus into the bladder. 



A 




^\XNXXNN\N\N\N\\\\\N\\\\\N\\\N\\\\^ 



B 



m\Mi\^\^\\\\\\\\\\\m\YA 



^^«^ 




Fig. 415. — Ureteral anastomosis. End to side. Van Hook's method. 



If the attack is especially severe, cystoscopic examination may be at- 
tempted. If, fortunately, the stone presents at the ureteral orifice, it may be 
removed, by the method subsequently to be described. If it is situated 
higher up, a ureteral catheter should be passed a short distance into the 
urethra and a small quantity of sterile oil injected. During the attack the 
patient should drink water freely. As the pain subsides, water should be 
taken in large quantities, together with a diuretic, to render the urine less 
acid or less alkaline, as the case may be. 

If a ureteral calculus presents at the ureteral orifice, attempts may 
be made to dislodge it by performing bimanual stroking or massage. The 
ureter may be located by inserting two fingers into the vagina, approxi- 
mating the tips of the fingers and the abdominal palpating hand along 
the course of the ureter and above the stone. The ureter is now stroked 
downwards toward the bladder, a maneuver that sometimes proves suc- 
cessful. The stone may be removed from the bladder with a delicate forceps 
passed through or alongside of a cystoscopy 

If the stone cannot be dislodged with bimanual manipulation, an attempt 
may be made to grasp it from inside the bladder with an alligator forceps. 



DISEASES OF THE KIDNEY AND URETER 



493 



If, however, the ureteral orifice is so constricted as to prevent the securing of 
a good purchase by the instrument or as to hinder extraction, the orifice 
may be dilated with a bougie or forceps. The injection of a small quantity 
of sweet oil into the ureter may facilitate the escape of the stone. 

Operative Treatment. — A stone in the ureter that is giving rise to no active 
symptoms may be disregarded for a time in the hope that it will pass. When it 
shows no tendency to do so, and all attempts to dislodge it by bimanual stroking, 
catheterization, or injection of oil fail; when characteristic pain persists, with no 
change in the position of the calculus ; and when the stone is so large as to 
preclude its spontaneous passage, operation is advisable. 

The form of operative procedure is dependent upon the location of 
the stone. 

Stone in the Upper Ureter. — The kidney and ureter are exposed by a 
lumbar incision and the stone is located by palpation. The ureter is sepa- 
rated from the surrounding fat, and a longitudinal incision I to i^ cm. in 
length, is made over the lower pole of the stone, which is then grasped 
with forceps and withdrawn. 





Fig. 416. — Ureterovesical anastomosis. (After Judd.) 

Stone at the Pelvic Brim. — The ureter is exposed by a muscle-splitting 
incision at about the level of the anterior-superior spine. The peritoneum 
is displaced mesially, and the iliac vessels are exposed. The ureter will be 
found close by, remaining attached to the peritoneum as it is lifted up and 
away from the vessels. The stone is located by palpation, the ureter is 
exposed, the calculus is fixed by grasping the ureter above and below, and a 
longitudinal incision is made directly over the upper or lower pole, which- 
ever one is most convenient. The stone is expressed or removed 
with forceps. 

Stone at the Pelvic Floor. — An incision is made in the semilunar line, 
below the anterior-superior spine. The peritoneum is pushed to the median 
line, and the iliac vessels and ureter are exposed. The stone is located by 
palpation, and one of two plans is adopted : either the stone is gently 
pressed upward, by palpation, to a higher level, where it can be easily 
reached, or the ureter is opened above the stone, at a convenient point 
and the stone extracted with a long, slender ureteral forceps. 

Stone in the Vesical Portion of the Ureter. — A stone in this situation 
may present many difficulties. If it is palpable per vaginam, the ureter 



494 



GYNECOLOGY 



should be exposed by an incision through the vaginal wall, the ureter opened 
by a longitudinal incision, and the stone extracted. 

When the stone is not palpable per vaginam, the ureter should be ex- 
posed extraperitoneally by an incision in the semilunar line. The dissection 
of the ureter is carried down to the point where the ureter passes beneath 
the uterine vessels. The latter are hooked up on the finger, tied in two 
places, a centimeter apart, and divided. The ureter can then be safely ex- 
posed in its lowest part. A longitudinal incision is made, and the stone 
extracted. Counter-pressure in the vaginal vault and base of the bladder by 
an assistant may greatly facilitate this procedure. 

Stone in the Intraparietal Ureter. — If a stone in that portion of the 
ureter that is situated in the bladder wall can plainly be felt per vaginam, 
it should be dealt with by division of the vaginal wall, dissection of the base 
of the bladder and terminal ureter, incision, and extraction. 




Fig. 417. — Method of implanting ureter into the intestine. (After Stiles.) 



When attack from below promises to be difficult, a transvesical exposure 
of the ureter may be made, after exposing the trigone by a suprapubic extra- 
peritoneal incision. But in most cases in women the procedure of choice 
consists in vaginal cystotomy with the patient in the knee-chest position. 
The incision through the vesicovaginal septum is made in the midline, about 
half-way between the internal ureteral orifice and the cervix. The position 
of the calculus is then determined by palpation, after which the correspond- 
ing area of the mucosa is exposed by means of suitable retraction. An in- 
cision is then made either through the rim of the ureteral orifice or close to 
the orifice in the line of the ureter, and the stone extracted. Closure of the 
vesicovaginal incision and the institution of continuous drainage of the 
bladder for a few days complete the operation. 

In all operations for stone in the ureter the periureteral sheath and its 
blood supply must be carefully conserved. When the stone is located it 
should be fixed by making compression of the ureter above and below, either 
by light, rubber-covered clamps or by the fingers of the operator or 
his assistant. 



DISEASES OF THE KIDNEY AND URETER 



495 



The ureteral incision should always be as small as will suffice for the ex- 
traction of the calculus, and always placed exactly in the median line. 

In every instance an attempt should be made to coapt the edges of the 
ureteral incision with a suture of fine catgut that includes the periureteral 
sheath and the muscular coat of the ureter, but not the mucosa. 

In extraperitoneal operations the wound should be drained for a few 
hours, but care should be taken that the drain does not come in contact 
with the ureter. 

After vaginal exposure of the ureter the vaginal incision should be closed 
with interrupted sutures. 

STRICTURE OF THE URETER 

Etiology. — Stricture of the ureter has been attributed to a variety of causes, 
among which may be mentioned congenital narrowing ; ureteritis from 




Fig. 418. — Method of implanting ureter into the intestine. (After Stiles.) 



the ordinary pyogenic organisms, the gonococcus, and the tubercle 
bacillus ; healing of a ureteral fistula following injury incident to labor, 
the Wertheim operation for carcinoma of cervix ; direct trauma, syphilis, 
and infection of the cervix. Hunner, who has made an exhaustive 
study of the subject, although admitting that any of the foregoing factors 
may play an active role in the etiology of ureteral stricture, is convinced 
that " the majority of ureter strictures, excluding those of tuberculous origin, 
should be classified as simple, chronic stricture ; they originate in an infec- 
tion carried to the ureter walls from some distant focus, such as diseased 
tonsils, sinuses, the teeth, or gastro-intestinal tract." " This conception of 
stricture," he asserts, " postulates that in the majority of cases ureter infil- 
tration is primary, and that the other urinary tract lesions, so often asso- 
ciated with stricture, such as stone in the ureter, hydronephrosis, pyelitis, 
and pyelonephrosis, are secondary." 

Symptoms. — Pain (i.e., nagging discomfort) at the site of the stricture is 
usual. With this there may be pain radiating upward toward the kidney, 



496 GYNECOLOGY 

laterally into the hips or groin, posteriorly, simulating a sacroiliac joint 
condition or sciatica, and downward into the thigh and leg in front or back. 
There is also in many cases intermittent pain in the kidney region, due to 
overdistention of the kidney pelvis. Bladder discomfort and frequency of 
urination are quite common in connection with the recurring renal attacks. 

Fever, chills, and leucocytosis, as in pyelitis, may occur intermittently 
when active urinary infection is present and the obstruction for some reason 
becomes more marked. Infected cases may go for weeks or months with- 
out chills or appreciable fever, the only symptoms being malaise and gen- 
eral depression. In rare cases febrile symptoms may be present when there 
is no infection of the urine ; in one case of this sort reported by Hunner the 
symptoms subsided after tonsillectomy had been performed. 

If there is an associated pyelitis, the urine displays the pathologic find- 
ings and variations common to that condition. If there is no urinary infec- 
tion, a few leucocytes or erythrocytes or both may, nevertheless, be found, 
or the urine may be quite normal. 

Gastro-intestinal symptoms are common, and consist of slight nausea 
and aversion to food or extreme and persistent nausea and vomiting, gase- 
ous distention, rectal tenesmus, and frequent desire to defecate, with pain 
just before or during the stool. As a result of the stricture colitis may occur. 

General symptoms indicative of disturbed kidney function have been 
noted, such as headache, nausea, etc., and in some cases morbid mental 
conditions have been observed. 

Pathology. — The inflammatory area varies from a slight, annular thick- 
ening in the wall of the ureter to a diffuse cartilaginous thickening that may 
be several centimeters in length and a centimeter in diameter. Multiple 
annular strictures are not uncommon. Associated with this condition there 
may be periureteritis; thus Hunner states that at operation he has often 
been unable to determine by palpation whether he is dealing only with a 
stricture or with a stricture plus stone. 

In by far the greatest number of cases the site of the stricture is in the 
broad ligament region, within 6 cm. of the bladder; the next most frequent 
location is at the bifurcation of the internal iliac vessels, or about 8 to io cm. 
above the bladder (3 to 5 cm. below the pelvic brim). In a series of 100 cases, 
70 were unilateral and the remainder bilateral. As regards the coexistence, 
in these cases, of urinary stasis, dilatation of the kidney pelvis, and urinary 
infection, which Hunner believes are secondary to stricture formation, an 
analysis of his cases showed that of the first 50 (an examination of urine 
for pus and cultures was not made in all) there were 16 non-infected and 18 
infected cases (colon, 13; staphylococcus, 4; typhoid, 1). The average 
capacity of the kidney pelvis in the non-infected group was 19 c.c. ; in the 
infected cases it was 98 c.c. (the average normal capacity is from 6 to 8 c.c.) ; 
the average duration of symptoms was greater in the first than in the 
second group. 

In the second group of cases, which were all studied bacteriologically, 11 
were infected (colon, 8 ; staphylococcus, 1 ; streptococcus, 1 ; unidentified, 
1). Four of the infected cases showed a pelvic capacity ranging from 15 to 
20 c.c; the average pelvic capacity was 16 c.c. The average duration of 
symptoms in the infected cases was shorter than in the non-infected. 



DISEASES OF THE KIDNEY AND URETER 497 

Hunner believes that many ureteral stones are unquestionably caused by 
ureteral stricture and are formed at the site of constriction. 

Diagnosis. — The diagnosis is based on the symptoms previously noted. 
In addition, local tenderness over the ureter at the pelvic brim may be 
elicited by palpation. In the vast majority of cases vaginal palpation will 
show the greatest tenderness in the broad ligament region, and at times the 
enlargement of the ureter can be detected. Cystoscopy is usually negative, 
but urethral stricture is quite often found. In Hunner's last 28 cases of 
ureteral stricture 27 had stricture of the urethra. When the stricture is in 
the bladder Avail region, slight redness and oedema may be found about the 
ureteral orifice. 

The decisive test is made by passing a wax-bulbed ureteral catheter. It 
is not the obstruction that is met on introduction, but the " hang " or catch 
of the wax bulb upon withdrawal of the catheter from the ureter, that is the 
determining factor. Pyeloureterograms after a sodium bromide or a 
thorium injection are useful, especially when the ureteral catheter cannot be 
made to pass the obstruction. 

Treatment. — The ideal method of treatment has for its object dilatation 
of the stricture from below. For this purpose ureteral catheters of various 
sorts and sizes may be used, either armed with a waxed bulb (pure bees- 
wax) or plain. In strictures of small caliber the passage of the catheter is 
often difficult or impossible. In these cases the olive, round-point, and 
whistle-tip catheter should be tried in succession. If all fail, a whalebone 
filiform bougie should be introduced to the point of obstruction, succeeded 
by another and still another until one finally engages in the lumen and 
passes through. This last filiform should be left in place and a smaller 
catheter be tried. Waxing the end of the catheter may facilitate its intro- 
duction, especially if the wax is given a corkscrew configuration and rotated 
as it engages the obstructed area. Dilatation of the stricture should be made 
either with plain catheters or with catheters with waxed bulbs of increasing 
size. For the first dilatation Hunner advises a waxed bulb no larger than 
3 to 5 mm. ; even at later periods the maximum size should not exceed 5 to 6 mm. 

The treatment should not be repeated oftener than once in ten days. 
thus permitting the traumatic oedema that follows the dilatation to subside. 
When pyelitis is present, lavage may be practised at ten-day intervals until 
some dilatation has been effected, when it may be employed oftener (twice 
a week). If the condition is bilateral, both sides should not be treated at 
the same sitting. 

When the stricture cannot be dilated from below, and especially if it is 
situated high up. some form of ureteroplasty may be required. A valve- 
like obstruction at the ureteropelvic junction, such as is seen in floating kid- 
ney, may sometimes be overcome by suspension of the kidney. 

Retrograde dilatation will often be more useful than ureteroplasty. 
The ureter is exposed by operation above the obstructed point, and cathe- 
ters or sounds of increasing size are passed downward through the stricture, 
dilating it from 5 to 7 mm. After this operative dilatation the stricture can 
usually be passed from below. 

Obstruction of the Ureter. — Obstruction of the ureter may be caused by 
compression due to a pelvic growth pressing; upon or invading its walls and 
32 



498 GYNECOLOGY 

sheath, as, for example, myomata of the uterus (especially the intraligament- 
ous and subvesical varieties) or carcinoma of the cervix or neighboring organs, 
which involves the cellular tissue in the bases of the broad ligaments. The condi- 
tion is slow in onset and may escape observation, being merged in the symptoms 
of the pelvic lesion producing the obstruction. In such cases it aggravates 
the condition of the patient and may be a very potent factor in hastening 
her decline. Thus, for example, obstruction of the ureter due to carcinomatous 
infiltration, often gives rise to no striking symptoms, and yet the gradually 
developing hydroureter, hydronephrosis, diminution in kidney function, and 
uraemia are solely due to the obstruction. This may also be true, but to a 
lesser degree, of a myoma or of any tumor that presses upon the ureter. 

Symptoms. — The symptoms that first attract attention to the condition 
are usually those of pyelitis, which occurs secondarily to the obstruction, 
and which will subside as soon as the obstruction is removed. 

Treatment. — The treatment of obstruction of the ureter from all these 
causes is the treatment of the provocative lesion. 

URETERAL FISTULA 

See Urinary Fistulse (Chapter XXIV, page 463). 

URETERAL LIGATION 

See Post-operative Complications — Suppression of Urine (Chapter 
XXXVIII, page 686). 

URETERAL TEAR OR INJURY 

See General Operative Technic — Injury to Viscera During Operation 

(Chapter XXX VI, page 642). 

BIBLIOGRAPHY 

Bacharach, R. : " Nephrektomie bei bilateraler Tuberkulose." Zeitsch. f . Urol., 1914, 
viii, 98. 

Binney, Horace: "The Value of High-Frequency Current in the Treatment of Vesical 
Papillomata." Boston Med. and Surg. Jour., 1913, clxviii, 308. 

Bissell, D. : "The Surgical Treatment of the Tubercular Ureter in the Female.'' S., G. 
and O., No. 5, 1915, xxi, 615. 

Braasch, Wm. F., and Moore, A. B. : " Stones in the Ureter." J. A. M. A., 1915, lxv, 1234. 

Cabot, H. : " Stone in the Kidney and Ureter." J. A. M. A., 1915, lxv, 1233. 

Cabot, H., and Crabtree, E. G. : " The Etiology and Pathology of Non-Tuberculous Renal 
Infections." S., G. and O., 1916, No. 5, xxiii, 495 ; Ibid. : " The End-Results of 
Seventy Cases of Renal Tuberculosis Treated by Nephrectomy." S., G. and O., 
1915, No. 6, xxi, 669. 

Clark, J. G., and Block, F. B ; : " Ultimate Results Following Nephropexy in Cases of 
Symptomatic Nephroptosis." Annals of Surgery, 1917, lxvi, 479. 

Clark, W. L. : " The Uses of Desiccation Surgery in Gynecology." Am. Jour. Obst, 1915, 
lxxii, 63. 

David, V. C. : "A Bacteriologic Study of Fifty Cases of Non-Tuberculous Diseases of the 
Bladder and Kidney." Surg., Gynec. and Obst., 1914, xviii, 432. 

Dietl: "Wandernde Nieren und deren Einklemmung." Wien. med. Wochenschr., 1864, 
Bd. xiv. 

Edebohls : " The Technic of Nephropexy." Annals of Surgery, 1902, xxxv. 

Eisendrath, D. N., and Kahn, J. V. : " Role of the Lymphatics in Ascending Renal In- 
fection." J. A. M. A., 1916, lxvi, 561. 

Ellis, E. G., with W. W. Keen and G. E. Pfahler : " On Hypernephroma." Amer. Med., 
1904, viii, 1039. 

Fenger: "Conservative Operative Treatment of Sacculated Kidney-Cystonephrosis." An- 
nals of Surgery, June, 1896, xxiii. 

Garceau, Edgar : " Treatment of Tubercular and Non-Tubercular Cystitis in the Female." 
Amer. Jour. Obst., 1907, lvi, 289. 



DISEASES OF THE KIDNEY AND URETER 499 

Geraghty, J. T. : "The Treatment of Chronic Pyelitis." J. A. M. A., 1914, lxiii, 2211. 

Geraghty, J. T., and Hinman, F. : " Ureteral Calculi ; Special Means of Diagnosis and 
Newer Methods of Intravesical Treatment." Surg., Gynec. and Obst, 191 5, No. 5, 
r xx, 515. 

Glenard : Les ptoses viscerales (estomac, intestin, rein, foie, rate) diagnostic et noso- 
graphie (enteroptoe, hepatisme). Paris, 1899. 

Hahn : " Die operative Behandlung der beweglichen Niere durch Fixation." Cent. f. 
Chir., 1881, Bd. viii, No. 29. 

Hunner, G. L. : "Ureter Stricture in Women." Trans. Amer. Gyn. Soc, 1917, xlii, 520; 
Ibid. : " Chronic Urethritis and Chronic Ureteritis Caused by Tonsillitis." Jour. Amer. 
Med. Asso., 191 1, lvi, 937; Ibid.: "The Diagnosis of Renal Calculus." Jour. Amer. 
Med. Asso., March 24, 1906; Ibid.: "Surgery of Urinary Tuberculosis in Women." 
Amer. Medicine, vii, No. 18, 701-707, April 30, 1904; Ibid.'. "Treatment of the Renal 
Pelvis and Ureter by Means of the Renal Catheter." Trans. Amer. Urological Asso., 
1909; Ibid.: "The Diagnosis and Treatment of Obscure Cases of Pyelitis and Hydro- 
nephrosis." International Clinics, iv, 22d Series ; Ibid. : " Malposition of the Kidney." 
Charlotte Medical Journal ; Ibid. : " Ureteral Stricture — Report of 100 Cases." Johns 
Hopkins Hospital Bulletin, January, 1918, No. s 2 3, xxix : Ibid.: "Tuberculosis of the 
Urinary System in Women." Johns Hopkins Hospital Bulletin, 1904, xv, 8 : Ibid. : 
Diseases of the Bladder and Urethra." Kelly-Noble, Gynecology and Abdominal 
Surgery, i, 438, 1907, W. B. Saunders Co., Phila. 

Israel, J. : " tiber Operationen wegen Uretersteinen." Folio Urologica, 1912, vii, 1 ; Ibid. : 
Chirurgische Klink der Nierenkrankheiten. Berlin, 1901. 

Kelly, H. A., and Burnam, C. F. : The Diseases of the Kidneys, Ureters and Bladder. 
D. Appleton & Co., N. Y. and London, 1914. 

Koll, I. S. : " The Experimental Effect of the Colon Bacillus on the Kidney." Jour. Amer. 
Med. Asso., 1915, lxiv, 297. 

Kretschmar, H. L., and Gaarde, F. W. : " The Treatment of Chronic Colon Bacillus 
Pyelitis by Pelvic Lavage." Jour. Amer. Med. Asso., 1916, lxvi, 2052. 

Kummell: " Modern Surgery of the Kidney." Surg., Gyn. and Obstet., January, 1907. 

Kuster: "Die Chirurgie der Nieren." Lief 52 b., Deutsche Chirurgie, Stuttgart, 1896. 

Montgomery, E. E. r Practical Gynecology. Blakiston, Phila., 1907, 2nd Edition, 920. 

Morris : Surgical Diseases of the Kidney and Ureter. London, 1901. 

Mayo, Wm. J. : " The Removal of Stones from the Kidney." Surg., Gyn. and Obst., 1917, 
xxiv, 1 ; Ibid. : " Procedures Following Nephrectomy." " The Managemnt of the 
Ureter After Nephrectomy for Tuberculous Kidney." Jour. Amer. Med. Asso., 1915, 
lxiv, 954, 957- 

Morton, J. J. : "A Rapid Method for the Diagnosis of Renal Tuberculosis by the Use of 
the X-rayed Guinea-pig." Jour. Exper. Med., 1916, xxiv, 419. 

Noble: " Some of the More Unusual Results of Movable Kidney." N. Y. Med. Jour., 1904, 
lxxix, 341. 

Oppenheimer, R. : " Die Pyelitis." Zeitschr. f . L T rol. Chir., 1913, i, 17. 

Pawlik, Carl: " Ueber die Harnleitersondirung beim Weibe." Archiv f. Klin. Chir., 1886, 
xxxiii, 717-739- 

Schede: Diseases of the Kidney. System of Surgery by v. Bergmann, edited by W. T. 
Bull, Phila., 1904, 262. 

Schenck : " Renal Hematuria of Unexplained Origin." Med. News, 1904, lxxxv. 

Stewart, D. D., and Kelly, A. O. J. : " On the Occurrence of Primary Tuberculosis of 
the Kidney, with Special Reference to a Primary Miliary Form." Med. News, August 
14-21, 1897, 193- 

Sweet, J. E., and Stewart, L. F. : " The Ascending Infection of the Kidney." Surg., Gyn. 
and Obst., 1914, vol. xix, 195. 

Taussig, F. J. : " Urethral Bacteria as a Factor in the Etiology of Cystitis in Women." 
Amer. Jour. Obst., 1906, liv, 465. 

Walker, G. : " Tuberculosis of the Kidney." Kelly-Noble, Gynecology and Abdominal 
Surgery, ii, 783. 

Walker: "Renal Tuberculosis." Johns Hopkins Hospital Reports, 1904, xii. 

Watson, B. P. : " Primary Malignant Tumors of the Female Urethra." Amer. Jour. Obst., 
1914, lxix, 795. 



CHAPTER XXVI 

DISEASES OF THE ABDOMINAL VISCERA RELATED TO, OR 
ASSOCIATED WITH, PELVIC DISORDERS 

Introduction. — The treatment of pelvic disorders by operation will fre- 
quently reveal lesions of the neighboring abdominal organs that demand 
immediate relief. Certain diseases of the suprapelvic or true abdominal 
viscera may give rise to symptoms that closely resemble those that are 
entirely pelvic in origin. The proper differentiation of the former from the 
latter, the recognition of disorders within the true abdomen in connection 
with pelvic disorders, and the complete and satisfactory management of the 
entire intrapelvic and intra-abdominal derangement, whatever it may be, 
require a familiarity with the symptoms, differential diagnosis, and treat- 
ment of the diseases of the entire abdominal viscera. In this volume our 
discussion will be limited to those organs situated near the pelvis and most 
frequently associated with pelvic diseases, i.e., the appendix, sigmoid flex- 
ure, and the rectum; appended to this is a discussion of the subject of 
visceroptosis, a condition that is more frequent in women than in men. 

APPENDICITIS 

Involvement of the Appendix in Pelvic Disease. — Involvement of the 
appendix is frequently associated with intrapelvic disorders, particularly 
with those of an inflammatory nature. In the latter case the participation of 
the appendix in the process is usually altogether a secondary matter, and 
only the outer coats of the appendix are involved — periappendicitis. The 
mucosa is unaffected except indirectly, by reason of the interference with its 
blood supply or with the continuity of its lumen because of angulation re- 
sulting from adhesions. The appendix suffers because it is in bad company. 

Secondary involvement of the right adnexa after a primary appendicitis 
is less common. This is due to a number of reasons: First, because opera- 
tion is usually undertaken at an early stage in appendicitis and the diseased 
organ is removed ; secondly, in neglected or perforating cases with spreading 
peritonitis, death ensues or recovery follows appendicectomy and drainage. 
The source of infection having been removed, the inflammatory process in 
the neighborhood rapidly declines, the inflammatory exudate is absorbed, 
and no permanent evidence whatever, or at most but a few adhesions imme- 
diately about the caecum, may be left behind. An appendiceal abscess may 
gravitate into the pelvis, especially if the appendix originally was unusually 
long or the caecum particularly low, in which event the ovary and the tube 
may be involved for a time. After evacuation of the abscess and drainage, 
the disorder will, in a majority of cases, rapidly subside and may leave no 
permanent mark. In some instances, nevertheless, chronic pelvic inflamma- 
tory disease is secondary to a previous attack of pelvic peritonitis compli- 
cating appendicitis (see Chapter VI, p. 96). The lesions consist of adhe- 
500 



DISEASES OF THE ABDOMINAL VISCERA 501 

sions between the uterus, adnexa, and pelvic peritoneum, closure of the 
tubes, thickening of the ovarian capsule, and cystic degeneration of the ovary. 

Secondary involvement of the appendix is more frequent after primary 
adnexitis, since in a vast majority of the latter cases the process is slower 
and runs a protracted course, during which the pelvic peritonitis with its 
exudate is likely to involve every structure lying within or at the brim of 
the pelvis. Infection sometimes extends to the appendix from the broad 
ligament along the right infundibulo-pelvic ligament. Appendicitis may be 
acute or chronic. The differential diagnosis between appendicitis and in- 
flammatory lesions of the right adnexa is of great importance. 

Differential Diagnosis Between Acute Appendicitis and Acute Adnex- 
itis. — The differential diagnosis is based upon a careful estimate of the 
history, symptoms, signs, and course of the disease. 

The history will show that an acute appendicitis is often preceded by 
digestive disturbances. It is more prone to come on without any preceding 
disability than are adnexal disorders. The onset frequently follows over- 
indulgence at the table, the ingestion of unwholesome food, and neglect of 
the bowels. The onset bears no relation to the menstrual periods, mis- 
carriage, or labor. 

Acute salpingitis and acute ovaritis are usually preceded by evidences 
of pelvic disturbance such as irritable bladder, leucorrhcea, disorders of 
menstruation, backache, etc. Inflammatory attacks most often take place 
about the time of the menses and shortly after abortion or labor. 

The symptoms of acute appendicitis consist, first, of pain in the epi- 
gastrium, nausea, vomiting, etc. ; later there are a localization of pain and 
tenderness about McBurney's point, and rigidity and spasm of the right 
rectus muscle, the pain is relieved by flexion and increased by extension of 
the right thigh. 

The temperature may be decidedly elevated (ioi° to 102 F.), but is fre- 
quently not much above normal (99° to ioo° F.) ; the pulse is affected more 
often than the temperature (90 to 120) ; nausea, vomiting, and constipation 
usually are marked; leucocytosis is rarely lower than 15,000, and may be 
20,000 or 25,000. 

In right adnexitis the pain is lower, nearer the median line, and may 
extend to the left side ; nausea and vomiting are less severe, but distention 
with gas probably more marked ; vesical or rectal irritability and pain are 
more frequently present, and the rigidity and tenderness affects the entire 
lower abdomen. Although flexion of the thighs relieves the pain, and ex- 
tension increases it, the movement of the right thigh alone does not so 
directly affect the pain as in appendicitis. 

The temperature is usually high (101 to 103 F.), and the pulse-rate 
correspondingly increased (100 to 130) ; the leucocytes are increased, but 
usually to a lesser degree in gonorrhoeal infections (10,000 to 15,000), and to 
a greater degree in post-abortal or post-partal ones (20,000 to 40,000). 

Streptococcus, staphylococcus, and colon bacillus infections almost 
invariably follow septic abortion or labor, or intrauterine manipulations, so 
that the history is especially important in making the diagnosis. 

The physical signs are of great value. The tenderness of acute appen- 



502 GYNECOLOGY 

dicitis is usually higher (McBurney's point) than in adnexitis, and more 
likely to extend to the right flank or upward toward the hypochondrium. 
The tenderness of adnexitis, as stated, is lower (just above Poupart's liga- 
ment), extending toward the median line to the opposite side, and to the 
front or the back of the thigh. A palpable mass above the pelvic brim on 
the right side is more likely to indicate an inflamed appendix than an in- 
flammatory enlargement of the right adnexa which is not detectable, as a 
rule, by simple palpation through the abdominal wall. 

Upon inspection of the genitalia in gonorrhoeal cases, one finds pus in the 
urethra or in Batholin's glands, or in a profuse, irritating, purulent dis- 
charge from the cervix ; in infections following labor or abortion, there may be 
recent abrasions, lacerations, ulceration, and false membrane. 

In the early stage, if the attack is an initial one, bimanual pelvic exami- 
nation may disclose nothing more than great tenderness, local heat, and 
swelling. The adnexa cannot be palpated because the abdominal wall is too 
rigid and the resistance of the patient is too great. The uterus may be found 
to be slightly enlarged, very tender, and somewhat fixed. In the course of 
from twenty-four to thirty-six hours the physical signs in the pelvis undergo 
a change. By this time there is less impediment to palpation, and the struc- 
tural changes that have occurred can be recognized. The uterus is fixed, 
the vaginal vault is hard, infiltrated, and very tender, and the evidence of 
pelvic exudate and inflammation are unmistakable. 

As regards the course of the disease, the symptoms of an adnexal inflam- 
mation rapidly subside, as a rule, under conservative treatment (see pages 414- 
416). By the end of twenty-four hours the pain will begin to diminish, the 
distention grow less, the fever and the pulse-rate be reduced, and the patient 
be decidedly on the mend. This is true, for the most part, of gonorrhoeal 
infections, but may not be so of a serious streptococcus infection. Since, 
however, the history or examination makes the evidences of the latter in- 
fection so clear, they need not be discussed here. While it is undoubtedly 
true that the milder forms of appendicitis frequently subside under appro- 
priate treatment, in appendix inflammations of the severe type, a subsidence 
is less likely to take place, the rigidity, tenderness, distention, and slight 
elevation of temperature and pulse continue, while the leucocyte count steadily 
rises. A word of caution must be spoken regarding the significance of a 
sudden relief from pain in bad cases of appendicitis. It often means 
that perforation has taken place. If this possibility is remembered, the 
flushed face, coated tongue, tender abdomen, gaseous distention, limita- 
tion of peristalsis, increased pulse-rate, etc., will leave no doubt in the mind 
of the examiner as to the true state of affairs. 

Treatment; — If appendicitis is positively diagnosticated and the patient 
is seen at the very onset and is in favorable condition, operation should be 
performed at once. In mild cases, if. the patient objects to operation or 
desires to postpone it until a more convenient time, palliative measures may 
be adopted for from twelve to twenty-four hours. 

When cases are seen late, the treatment should be modified according to 
the conditions that are found. If there are evidences of a spreading peri- 
tonitis, progressive distention, limitation of peristalsis, increase in pulse-rate 



DISEASES OF THE ABDOMINAL VISCERA 503 

and in the number of leucocytes, etc., operation should be performed at 
once. If tumor formation has occurred and there are no indications of a 
diffuse peritonitis, the case may be treated expectantly for a few hours, in 
order to determine, as nearly as possible, whether the condition is advancing 
or retrogressing. If the symptoms do not abate, operation is indicated. 

Not infrequently the symptoms remain in abeyance or tend to subside, 
and the tumor shrinks and finally disappears, or nearly so. In such cases 
operation should invariably be advised, but a later date selected. The ad- 
vantages gained by waiting are a clean operation, less danger of spreading 
infection, fewer adhesions, and less trauma to the intestine. Every surgeon 
of experience has regretted operating in the stage of plastic exudate, when 
the appendix is buried and both it and the surrounding intestines are friable 
and difficult to handle. If the operation is performed two months later, 
when the process has subsided, it becomes as simple as the interval opera- 
tion of a recurrent catarrhal appendicitis. 

The palliative treatment of acute appendicitis comprises rest in bed, 
abstinence from food, and the application of an ice-bag to the right iliac 
fossa. If distention is distressing, the lower bowel may be emptied by a 
small enema (i pint), by the passage of a rectal tube, or by the exhibition 
of suppositories of asafetida. No cathartics should be administered. 

In cases seen later, with tumor formation but without evidences of 
spreading peritonitis, abstinence from food, the Fowler position, proc- 
toclysis, and the application of an ice-bag to the affected area should be 
prescribed. After the symptoms have begun to subside, resolution may be 
hastened by the application of heat. The bowels may be moved daily by 
means of a small, carefully given enema, and the return to food be begun 
very cautiously and the diet increased only as the symptoms continue to 
subside. Only after complete subsidence has occurred is the administration of 
a cathartic permissible. 

CHRONIC APPENDICITIS 

Chronic appendicitis is usually a low-grade inflammation, the sequel to 
an acute attack. It may develop without acute manifestations. 

The appendix may be elongated and hypertrophied, adherent, kinked, and 
distended with gas or with fecal concretions. Whatever the pathologic con- 
dition, there is interference with the normal drainage of the appendix into 
the caecum or with the peristaltic action of the neighboring intestine. 

Symptoms and Diagnosis. — The symptoms of chronic appendicitis con- 
sist of pain and soreness about McBurney's point, general abdominal dis- 
tention and flatulence, diarrhoea, and constipation. Indiscretions in diet, 
neglect of the intestinal functions, and overexertion usually increase the 
symptoms. A rigid enforcement of dietary regulations, a daily laxative, and 
avoidance of exertion tend to diminish them. When the appendix is adher- 
ent to the pelvic structures, the recurring menstrual function may cause a 
periodic aggravation of symptoms, due to a congestion in the blood supply. 

Differential Diagnosis Between Chronic Appendicitis and Chronic Ad- 
nexitis. — A differential diagnosis between chronic appendicitis and a lesion 
of the right tube and ovary may be necessary when the appendix is low and 



504 



GYNECOLOGY 



the ovarian or tubal disturbance consists merely of adhesions to the sur- 
rounding structures. Such attachment of the tube and ovary may be diffi- 
cult to diagnose if the adnexa are not enlarged and if they retain a fair 
degree of mobility. In the case of adnexal disease the symptoms are usually 
more marked at the menstrual periods. 

If the lesion is in the appendix, there is a predominance of the intestinal 
symptoms, tympanites, flatulence, occasional abdominal distress after eat- 
ing, constipation, and diarrhoea. 






Fig. 419. — Appendicectomy: (A) ligation of meso-appendix; [B) ligation of appendix and line of divi- 
sion of meso-appendix; (C) circular suture with loop at vascular area; (.D) inversion of stump; (E) stump 
of meso-appendix drawn over inverted base. 

In adnexal lesions, chronic pelvic symptoms, backache, irregular menses, 
dysmenorrhoea, vesical irritability, leucorrhcea, etc., are more prone to occur. 

Bastedo's sign (the production of pain in the appendix region on disten- 
tion of the colon with air) may be looked for. 

When both the appendix and the adnexa are involved, the symptoms of 
both conditions are combined. Recurrent exaggeration of appendix symp- 
toms at the menstrual periods is often indicative of adhesions between the 
right adnexa and the appendix. 



DISEASES OF THE ABDOMINAL VISCERA 505 

When a positive differential diagnosis can be made only with difficulty, 
examination under anaesthesia may be useful. The complete relaxation thus 
obtained permits detection of even slight enlargement or restriction of 
mobility of the adnexa. 

OPERATIVE TECH NIC 

The treatment consists in appendicectomy. This may be performed in a 
number of ways, as may be seen from the accompanying illustrations. The 
operation is a simple one except when the appendix is densely adherent. 

In performing operations upon acute cases, with spreading peritonitis, 
several important points must be borne in mind : 

i. The patient should be kept in the elevated (semi-Fowler) position 
before, during, and after the operation. 

2. A right rectus (Battle's) incision, of ample proportions to give a good 
exposure, should be made. 

3. The appendix should be located by palpation and exposed by packing 
the intestines away from the appendix area with gauze wrung out of hot 
salt solution. 

4. The appendix should be removed by the simplest method, and no 
attempt should be made to peritonealize the stump unless the caecum is not 
involved and the procedure can be easily and rapidly carried out (Figs. 
419 and 420). 

5. Drainage should be provided by rubber tubes with gauze wicks — ■ 
one going to the bottom of the pelvis, and the other to the right iliac fossa. 
The gauze packs should be left in situ until the drains are placed in position. 

6. The peritoneum may be closed by continuous suture, but the fascia 
and skin should be closed with interrupted sutures placed a good distance 
apart, so as to encourage free external drainage. Most of the sutures should 
be of catgut, but a few supporting sutures of silkworm gut should also 
be used. 

7. Nitrous oxide-oxygen-ether anaesthesia gives the best results. 

8. Continuous enteroclysis and postural drainage (Fowler or semi- 
Fowler position) should supplement the operative treatment (for man- 
agement of drains see page 661). 

INTESTINAL STASIS 

Acute Intestinal Stasis. — Acute intestinal stasis, or acute intestinal ob- 
struction, is rare as a complication of pelvic disease, and its differentiation 
from pelvic disorders is not often demanded. Disease originating in the 
pelvis very rarely produces an acute obstruction of the alimentary canal. 
That acute obstruction may follow pelvic operations is true, and such a 
condition is discussed on page 680. Certain forms of acute intestinal ob- 
struction, as, for example, intussusception, volvulus, etc., are prone to 
occur at the extremes of life, when acute pelvic disorders, with the possible 
exception of twisted pedicles, may be excluded. It is remarkable that 
pelvic inflammatory disease and pelvic tumors, although they encroach 
upon or compress or bind with adhesions the large and small intestinal 
loops that are found in the pelvis, almost never cause more than moderately 



506 



GYNECOLOGY 




^v- 






Fig. 420. — Appendicectomj*. _ Clark's method. (A) Ligation of meso-appendix; (B) division 

of meso-appendix and crushing of base; t-he appendix is cut away close to the clamp with 

a cautery knife; (C) inversion of stump; (D) sero-serous suture. 



DISEASES OF THE ABDOMINAL VISCERA 



507 



severe and rapidly subsiding indications of acute obstruction of the intes- 
tinal tract. For a discussion of the varieties, causes, etc., of acute intestinal 
stasis the reader is, therefore, referred to works on abdominal surgery. The 
symptoms and treatment of the condition, so far, at least, as they apply to 
the post-operative complications of intestinal obstruction, will be found in 
Chapter XXXVIII. 

Chronic Intestinal Stasis. — Chronic intestinal stasis frequently occurs in 
women. It may be the result of intrinsic pelvic disease, enteroptosis, re- 
dundancy, overdistention and angulation of certain parts of the intestinal 
tube, and intestinal adhesions. 

Chronic Intestinal Stasis from Pelvic Diseases. — Pelvic diseases are fre- 
quently responsible for chronic stasis of the intestinal tract. The inter- 
ference with the function of the bowel may be due to direct compression of 
the large intestine by pelvic tumors, as in 
the case of nbromyomata of the uterus, 
or by reason of pelvic exudates or adhe- 
sions that bind the intestinal loops to- 
gether or to adjacent structures, and pro- 
duce angulation. It is often a source of 
wonder to the pelvic surgeon that the dis- 
tortion or compression of the intestines 
within the pelvis met so frequently with 
inflammatory lesions has not given rise 
to acute obstructive symptoms. Relaxa- 
tion of the pelvic floor, with rectocele and 
impairment of the forces normally en- 
gaged in defecation, is a frequent source 
of chronic engorgement of the rectum 
and sigmoid. 

Chronic Intestinal Stasis from Ente- 
roptosis. — Enteroptosis is frequently seen 
in women who have borne children, 
and is commonly associated with a 
relaxed and pendulous abdomen. In a certain proportion of cases it con- 
stitutes a developmental defect, being the result of ill nourishment during 
adolescence or earlier life, insufficient exercise, improper clothing, faulty 
habits of work, etc. Whatever the cause, the end-result in one case has 
certain features common to all other cases. In the normal individual the 
shape of the abdominal and the pelvic cavity on sagittal section is grossly 
triangular (Fig. 421), the base of the triangle being directed toward the 
diaphragm. In the erect position the posterior abdominal wall is consid- 
erably inclined forward. This furnishes a sort of shelf from which the 
mesenteries and retroperitoneal supports arise, and upon which the viscera 
find partial support. The preservation of this triangle depends largely upon 
the strength and tonicity of its anterior face, viz. the anterior abdominal 
wall. In individuals of poor general muscular development this may be 
flabby and relaxed, or it may have undergone atrophy from disuse and 
pressure after the individual began to wear corsets ; or its strength may have 
become impaired by overstretching, as in pregnancy, or by the presence of 




> r- Diaphragm 

--/---Spin&l Column 

-II ice Crest 



Fig. 421. — Triangular shape of the abdominal 
cavity on sagittal section. (After Dickinson.) 



508 



GYNECOLOGY 



an abdominal tumor. Defects in body, form, or posture affect the inclination 
of the posterior abdominal wall, which becomes almost vertical. This takes 
away a certain amount of support from the abdominal viscera, which then 
display a tendency to slide downward. 

Intestinal stasis from enteroptosis is less likely to occur when the ptosis 
affects all the abdominal viscera than when it is limited to certain parts of 
the intestinal tract. If all the viscera are equally ptosed, without adhesions 
(Fig. 422), angulation and kinking of the intestinal tube may not occur. 



Diaphragm — ._ 



Anterior surface 
of stomach 

G&stro-splenic I I 
Ligament rl 



Post surface 
of Stomach — 

Transverse 
Meso-colon 



Transverse 
colon — 




I Tcvi\ of 
P&ocreos 



Duodenum 

Left 
"kidney 



""-Sigmoid 



Small intestine 



Fig. 422.— General ptosis. Sagittal section through left side of abdominal cavity showing absorption 
of extraperitoneal fat and the downward displacement of all abdominal organs constituting a general 
ptosis. The belly is pendulous, the lumbar curve is gone and the patient has assumed the "carry- 
ing position." C After Coffey.) 

When only a part is ptosed, the other parts being fixed or held in their 
normal position, angulation and obstruction are quite the rule. The most 
common variety of partial enteroptosis is midline ptosis — that is, the trans- 
verse colon and the middle part of the stomach are prolapsed below their normal 
level (Fig. 423)- The pyloric and the cardiac ends of the stomach and the duo- 
denum, as well as the splenic flexure of the colon, remain fixed. 

Partial enteroptosis may affect also the caecum (Fig. 424) (caecum 
mobile) and the ascending loop of the colon, under which conditions, par- 



DISEASES OF THE ABDOMINAL VISCERA 



509 



ticularly, obstruction may occur at the splenic flexure or at the ileocecal 
junction. Partial enteroptoses are frequently associated with ptosis of the 
right kidney. When both kidneys are involved, all the abdominal viscera 
are prolapsed. 

Redundancy, Kinking, and Overdistention of the Colon. — Redundancy 
and overdistention of the colon may result from constipation, the frequent 




Fig. 423. — Midline ptosis. Middle pyloric portion of stomach and transverse colon 

prolapsed while the fixed points at the esophagus, duodenum and colonic flexures, 

as well as the kidneys, remain in normal position. (After Coffey. ) 

use of enemas, or atony of the intrinsic muscle of the intestinal coats. As 
seen clinically, it is often difficult to decide whether the condition of the 
bowel is the cause or the result of the symptoms that are present. What- 
ever its significance, the affected portion of the intestine is distended, its 
walls are thinned out and atonic, increased in length, and therefore abnor- 
mally coiled and angulated. The sigmoid is the part of the intestinal tract 
that is most often redundant and overdistended, but the entire colon — de- 
scending, transverse, and ascending — may be affected. In advanced cases 



510 



GYNECOLOGY 



of intestinal stasis due to enteroptosis this is usually the case, especially it 
the subject has been neglectful as regards the intestinal function and is of a 
relaxed, asthenic habit. 

Chronic Intestinal Stasis from Adhesions Between Intestinal Loops or 
Between the Intestinal and the Parietal Peritoneum or the Mesenteries or 
Omentum. — Such adhesions may be congenital or acquired, and are found 
in various situations : 

First: About the ileocecal junction, involving especially the terminal 
portion of the ileum. The adhesion may take the form of an accessory 
mesentery, attaching the normally free surface of the ileum to the peritoneum 

of the iliac fossa or pelvis, 
or to the intrinsic mesentery 
of the ileum itself, or a band 
of adhesions may form be- 
tween the ileum and the 
pelvic organs or the 
caecum ; or the ileum 
may be rolled, as it were, in 
its own mesentery, and be 
adherent there. A n y of 
these varieties of adhesions 
may produce a kink or an 
angulation of the ileum. 
Attention was first drawn 
to them by Lane. They 
interfere with the 
proper discharge of the con- 
tents of the ileum into the 
caecum, and thus are a fac- 
tor in many cases of intes- 
tinalstasis. 

Adhesions may also be 
found about the head of the 
caecum and the first part of 

due to incomplete rotation and fusion of colon. The colon hangs +V, P ocppnrlino- rolnn TVlf^P 
from the bottom and under border of the kidney and duodenum. inC d^cliumg cuiUIl. J. IICSC 

(After Coffey.) bind the intestine to the 

lateral and posterior parietal peritoneum or to the neighboring omentum, 
fixing the intestine in that position and producing stasis by interference 
with peristalsis or by actual kinking, especially if such adhesions coexist 
with midline ptosis, as is often the case. 

Secondly : Adhesions not infrequently form between the loops of the sig- 
moid flexure. These often involve the mesosigmoid, which is folded or 
contracted upon itself, bringing two contiguous parts of the intestinal tube 
almost parallel and kinked at their junction. This is another source of 
obstruction to the fecal current. 

The genesis of such adhesions is not always clear. They must often, 




Fig. 424. — Right-sided ptosis. Unfused caecum and ascending colon, 



DISEASES OF THE ABDOMINAL VISCERA 



511 



however, be congenital, and result from abnormalities in fusion and forma- 
tion during embryonal life or be due to foetal peritonitis. They are also occa- 
sioned by inflammatory processes originating in the appendix (residua of an 
acute or chronic appendicitis), sigmoid (extension from a diverticulitis), or 
the intestine itself (catarrhal enteritis). Constipation may undoubtedly pro- 




Fig. 425. — Exercises for ptotic patients. Simple means of obtaining Trendelenburg 
position. Position advised for exercises prescribed for ptotic patients. (.After Martin.) 

duce them as a secondary manifestation which is often mistaken for the 
primary cause. 

Symptoms. — The symptoms of chronic intestinal stasis consist of chronic 
constipation, possibly interrupted with occasional attacks of diarrhoea, intes- 
tinal pain, gaseous distention, general digestive unrest, anorexia, coated 




Fig. 426. — Exercises for ptotic patients. • Exaggerated expansion of the chest with arms 
above the head. (After Martin.) 

tongue, foetid breath, headache, malaise, lack of assimilation, anaemia, toxic 
dermatitis, etc. The severity of the symptoms usually corresponds to the 
degree of constipation that is present. 

Diagnosis. — The degree of constipation may be estimated by the meas- 
ures that are required to secure a satisfactory movement of the bowels. 



512 



GYNECOLOGY 



Treatment. — In the treatment of intestinal stasis conservative measures 
should invariably be exhausted before surgical aid is sought. When, how- 
ever, the cause is evidently an organic lesion that will not yield to palliative 
measures, operative intervention should be undertaken. To be specific : if 
pelvic inflammatory disease, a pelvic tumor, or a chronically diseased appen- 
dix is present, the seat of the disease may be removed at once. In entero- 
ptosis, however, either with or without adhesions, the best that surgery can 
offer is not always easy to determine, and it is well, therefore, to hold this 
form of treatment in reserve. 

Even with the help of the Rontgen ray one is often unable to predict what 
surgery can accomplish. In spite of anything the Rontgen ray may show, there- 
fore, in the way of ptosis, kinks, obstruction, etc., one should first learn the 




FlG. 427. — Exercises for ptotic patients. After extreme extension of the legs, one at a time 

and then together, leg is flexed upon thigh and thigh upon abdomen, followed by return to 

extended horizontal position. (After Martin.) 



effect of non-operative measures that aim to restore the ptosed organs to 
their normal position. This last is best accomplished by postural treat- 
ment ; when the trunk is inclined toward the diaphragm (Trendelenburg 
position, knee-chest, or Sims' position), the abdominal viscera gravitate in 
that direction. Even when the erect posture is resumed the restoration may 
be maintained, at least for a time, by properly supporting the anterior 
abdominal wall. 

The postural treatment may be combined with exercise that tends to 
strengthen the anterior abdominal muscles (Figs. 425, 426, and 427). The 
anterior abdominal wall is best supported by means of a corset. 

The frequency and power of the intestinal movements may be influenced, 
first of all, by a diet that leaves a large residue in the intestine, lubricates the 
intestinal lining, or stimulates the production of the normal peristaltic- 
persuading juice (bile). The bulky vegetables and cereals, such as potatoes, 



DISEASES OF THE ABDOMINAL VISCERA 513 

baked or mashed, spinach, cabbage, turnips, parsnips, beets, oatmeal and 
cream, mush and cream, etc., are useful for this purpose. Fat meat, prunes, 
figs, dates, and baked apples are also helpful. The articles of diet that should 
be taken sparingly are those that are almost entirely digested in the intes- 
tinal tract, such as milk, eggs, lean beef or mutton, etc. In addition to 
regulating the diet, exercise is of paramount importance ; besides the postural 
exercises mentioned, walking, tennis, golf, dancing, with the abdominal wall 
well supported, if not carried to the point of fatigue, may be of some value. 
Massage of the abdominal wall has a distinct field of usefulness. 

The establishment of the habit of going to stool at a definite hour, 
when there is plenty of time, and making an effort to defecate, whether 
the impulse is present or not, are helpful. Immediate relief cannot be ex- 
pected from any of these measures or from a combination of them but, 
except in the worst cases, persistence will bring success. Until success- 
ful results are secured, and especially if improvement is slow, laxa- 
tives of some sort must be prescribed. Of these the most satisfactory is a 
combination of cascara (2 grains), rhubarb (1 grain), licorice (1 grain), and 
podophyllin (1/24 grain). Other formulas are as follows: 

B Aloini gr. 1/5 

Strychninse gr. 1/120 

Ext. belladonnas fol gr. 1/8 

Ext. rhamnus purshianse gr. 1/2 

One or two such pills to be taken at night. 

or 

B Fl. ext. rhamnus pursh 

Fl. ext. rhei aa Si 

Fl. ext. sennae Hii 

M et Sig. : One to two fluiddrams at night. 

These remedies may be administered in decreasing dose as the case pro- 
gresses, and finally, if possible, discontinued. In making a selection of the 
particular formula, it is well to bear the idiosyncrasies and preferences of 
the patient in mind. Of late much use has been made of chemically pure 
paraffine oil. This is a tasteless and odorless intestinal lubricant. It is 
marketed under various trade names. When this oil is exhibited (1 to 4 
drams thrice daily), the patients acquire, in the course of a few days, a 
feeling of insecurity as regards the restraining power of the sphincter ani, 
and may be inclined to discontinue the remedy. A little encouragement, 
careful regulation of the dose, and the assurance that this feeling will dis- 
appear or be under control within a short time will serve to restore the 
patient's confidence. The patient sometimes prefers to take a single large 
dose at bed-time (4 to 8 fluid drams). As the oil is a lubricant only, it is 
often advantageous to combine with it a laxative such as the fluidextract of 
cascara (10 to 60 drops). 

If anything more is required, suppositories and enemas may be employed, 
the latter being the most satisfactory. Either hot water and Castile soap, or 
the combinations mentioned under post-operative treatment (page 665), may 
33 



514 



GYNECOLOGY 



be used. Gluten or glycerin suppositories may serve to supply the impetus 
for evacuation. 

Injections of paraffine oil are occasionally successful. About four to eight 
ounces of the warmed oil should be injected slowly through a large catheter 
passed high into the bowel, the patient lying on her left side with the hips 
elevated. After fifteen minutes in this position the patient may turn upon 
her back, the hips still being kept elevated. The patient should sleep upon 
the right side, with the hips higher than the trunk. The quantity of oil given 
should not be large enough to induce violent peristalsis. Oil administered in this 




Fig. 428. — Beyea's operation. Suturing of the gastrohepatic omentum. 



way upon retiring will sometimes secure a satisfactory stool the 
following morning. 

Granulated agar-agar (vegetable gelatin), taken with a cereal in the 
morning, is often of much benefit in softening the faeces and lubricating the 
intestinal mucosa. 

For emaciated patients Coffey advocates the rest cure, with forced feed- 
ing and the frequent assumption of the " elevated hips " position. In this 
way he seeks to deposit fat within the leaves of the lean and overstretched 
mesenteries, with a consequent shortening and increase in tone. Under 
such a plan he has in a number of cases improved the position of the abdom- 



DISEASES OF THE ABDOMINAL VISCERA 



515 



inal viscera, and recommends that this method be used before resorting to 
surgical treatment. 

The surgical treatment of intestinal stasis may consist of any one or any 
combination of two or more of the following operations : 
I. Elevation of the stomach (gastropexy). 
Suspension of the colon (colopexy). 
Division of adhesions. 

Intestinal anastomosis and short circuiting. 
Resection of the intestine. 

Contraction or expansion of the abdominal parietes. 
The particular operation or operations chosen will depend on the nature 
and number of the lesions revealed by an exploratory incision. The Rontgen ray 




Fig. 429. — Gastropexy; Coffey's opera- 
tion. The omentum is sutured to the 
anterior abdominal wall. (.After Coffey.) 



Fig. 430. — Diagram illustrating the placing 
of the sutures for shortening the gastro- 
hepatic omentum, Beyea's operation, and 
for suturing of great omentum to the ante- 
rior abdominal wall, Coffey's operation. 
(After Coffey.) 



will often furnish accurate knowledge of the lesions before operating. 
Nevertheless, the interpretation of the Rontgen ray is not free from error, 
and its findings should be verified or confirmed by making an examination 
after the abdomen is open. 

1. Gastropexy. — The stomach participates in midline ptoses. Although 
the dropping of the stomach below its normal level does not produce intes- 
tinal stasis, if it is giving rise to symptoms as an associated condition, such 
as gastric retention, etc., it requires correction. The best type of operation 
is that devised by Beyea, which consists in shortening the gastrohepatic liga- 
ment. The technic of the operation may be learned from the accompanying 
illustrations (Figs. 428, 430, and 431). 

2. Colopexy. — Midline ptosis of the colon with angulation at the splenic 
flexure, or at both the hepatic and the splenic flexure, may be corrected by 



516 



GYNECOLOGY 



the operation of Coffey, which attaches the gastrocolic and the upper areas 
of the great omentum to the anterior abdominal parietes (see the accompanying 
illustrations, Figs. 429, 430, and 431). 

Ptosis of the ascending colon or of the caecum (caecum mobile) may be 
treated by the operation of Wilms, as practised by Frazier. He makes a 
vertical incision in the parietal peritoneum about one inch from the peri- 
toneal reflexion on the outer side of the caecum. A pocket is made for the 
caecum by dissecting the peritoneum off a distance of an inch above and 
below the line of incision. The caecum is then secured in place by a con- 
tinuous suture of linen introduced through the margin of the peritoneal in- 
cision above described, and the longitudinal band of the caecum. 

Ptosis of the sigmoid flexure may be treated after the plan of Murphy. 
For this operation an incision is made through the outer margin of the left 
rectus. The sigmoid and the rectum are drawn up as high as they will go 




Fig. 431. — Scheme of completed Beyea and "hammock" operation. 
(After Coffey.) 

with moderate traction. The peritoneum of the posterior abdominal wall is 
then divided above the pelvic brim and the outer side of the ureter for a 
distance of four to five inches. A flap of peritoneum is next freed from its 
posterior attachments in a direction outward from this incision. The sig- 
moid is rolled into the raw, denuded area, and is secured to the muscles be- 
hind the peritoneum by means of a continuous catgut suture. The peri- 
toneal flap is folded medianward around the sigmoid, and accurately sutured 
to it near the mesosigmoid. The under surface of the peritoneum becomes 
fixed, and the sigmoid, in turn, becomes permanently adherent to the retro- 
peritoneal muscles and aponeurosis (Fig. 433). 

3. Division of Adhesions. — Pericolic adhesions should not be interfered 
with unless they give rise to obstruction by anchoring the caecum too high or 
too low. If this is the case, they should be divided and the raw surfaces peri- 
tonealized or protected as far as possible. 

Adhesions and supernumerary mesenteries about the lower ileum caus- 






DISEASES OF THE ABDOMINAL VISCERA 



517 



ing Lane kinks should be divided, and the raw surfaces so disposed as to 
prevent their reformation and yet release the bowel. 

Adhesions between the loops of the sigmoid flexure may be prevented 
from reforming by performing suspension after Murphy's plan, or if the 
bowel is exceedingly redundant, the denuded part of the intestines may 
be resected. 

Adhesions between loops of the small bowel should not be interfered 
with if there is no angulation ; if they cause a kink or an angulation, they 







O 



\Xvt\VvY\cu.* 

Fig. 432. — Suspension of the hepatic flexure, Reed's method. The colon covered 
by the base of the omentum is being attached to the everted transversalis fascia. 



should be freed and the raw surfaces protected (see pages 641 and 643). 
If the released bowel is in bad condition, resection may be performed. 

The release of post-operative adhesions between the omentum and the 
lower abdominal wall or appendicular or pelvic region may at once dispose 
of a ptosis of the stomach or colon entirely due to traction. If, however, the 
colon and stomach are in their normal position and the adhesions of the 
omentum are high attaching the colon to the abdominal parietes, they may 
often, with advantage, be disregarded. 



518 



GYNECOLOGY 



After the release of adhesions in any part of the abdomen the posture of the 
patient should be such as to insure the retention of the viscera in or above their 
normal position, or nearly so. For this purpose the foot of the bed should 
be slightly elevated, and the patient encouraged to turn from side to side ; 
if adhesions then reform, the obstructive symptoms will not necessarily 
recur. It is also wise to stimulate peristalsis by the exhibition of pituitrin 
and the early administration of a laxative. 

4. Intestinal Anastomosis and Short Circuiting. — An area of obstruction 




Fig. 433. — Suspension of sigmoid (after Murphy, from Kelly and Noble) ; (bbb) shows ele- 
vation of retroperitoneal flap and subperitoneal suture line to sigmoid. (Courtesy W. B. 

Saunders Co.) 



in the intestinal tract may be excluded by anastomosing a point above to a 
point below the obstructed area. This method is known as short 
circuiting. Aside from obstruction due to new growths, which is not perti- 
nent to this discussion, such an anastomosis is most frequently made be- 
tween the terminal part of the ileum and the sigmoid flexure. This excludes 
the ileocsecal junction, hepatic and splenic flexure, and with them the ob- 
struction to the fecal current so frequently observed in those localities. 
Technically, the operation is a simple one. As experience accumulates, the 
frequency of backflow and accumulation of faeces in the excluded area will 






DISEASES OF THE ABDOMINAL VISCERA 



519 



be determined. Upon this depends the ultimate place in surgery of the 
short-circuiting operation. 

5. Resection of the Intestine. — Resection of the intestine may be indicated 
by: (1) Extensive tearing of the intestine after separation of adhesions. 










#. 






x- 



~i-x 







x~ - 




Fig. 434. — Points of anastomosis and obstruction in the gastro-intestinal tract. 



(2) Redundancy, dilatation, and an unhealthy condition of the bowel. 
Resection may be applied to the ileum, the ileum and caecum, the sig- 
moid and the ilium and the entire lower colon as far as the sigmoid flexure. 
In the most extensive form, resection of the bowel for intestinal stasis 



520 GYNECOLOGY 

rids the patient of intestine that cannot be placed in a normal position, of 
intestine that is almost certain to become adherent and cause obstruction, 
or of intestine that is so badly damaged or so distended, elongated, ptosed, 
and atonic, that it will probably never functionate properly. 

This is often a serious operation. The form most commonly applicable 
is resection of the terminal ileum, caecum, and ascending and part of the 
transverse colon. The proximal end of the ileum is then anastomosed with 
the transverse colon. 

6. Contraction or Expansion of the Abdominal Parietes. — Although Coffey 
has devised operations for the purpose of expanding the upper and con- 
tracting the lower abdomen, they are so difficult to execute successfully as 
to be rarely of practical use. Expansion of the upper abdomen is best 
secured by the adoption of postural methods combined with exercises that 
tend to develop the lower thorax. When relaxation of the lower abdomen 
is largely featured by diastasis of the rectus muscles, a reduplication of the 
overstretched fascia between them after the plan of Webster, gives excel- 
lent results. In these cases we need not, however, rely on surgery alone to 
support the abdominal wall, for the median overlapping of fascia and the 
excision of redundant fat may be satisfactorily augmented by the applica- 
tion of a suitable corset or an abdominal bandage. 

DIVERTICULITIS 

Etiology. — Inflammation of diverticula of the mucosa of the intestine 
affects principally the sigmoid. Meckel's diverticulum of the lower end of 
the ileum also may be the seat of a diverticulitis. It is a rarely recognized 
condition, but is more common than is generally believed. Small pockets of 
the mucosa are formed which penetrate the wall of the gut, following the 
course of the veins. The diverticulum may end beneath the serous coat or 
pass further into an epiploic appendage, or it may not go beyond the muscu- 
lar coat. The condition is usually multiple. 

The diverticula may be congenital or acquired (as from constipation). 
They are, generally, for a time, the seat of a subacute or chronic inflamma- 
tory process. This finally results in either a gradually formed hypertrophy 
of the intestine in the area of the diverticulum resembling a new growth, or 
the inflammatory process may extend to the peritoneal surface or into an 
epiploic appendage and produce a sharp attack of pelvic peritonitis 
or epiploitis. 

Symptoms. — The symptoms are usually slow in origin, and extend over 
a long period of time. There is a tendency toward diarrhoea, blood and 
mucus appearing in the stools, and pain is present. When, conjoined with 
these symptoms, a mass develops in the left iliac region, the suggestion of 
malignancy is very strong, and nothing but an exploratory operation, or 
even a laboratory examination of the removed section of the bowel, will 
show the process to be entirely inflammatory and not malignant. If the 
process suddenly becomes acute, the symptoms strongly resemble those of 
an appendicitis, except that the pain, rigidity, and tenderness are on the 
left side. 



DISEASES OF THE ABDOMINAL VISCERA 521 

Treatment. — In the chronic forms, with tumor formation, the diseased 
area should be resected. 

In acute cases the affected epiploic appendage should be removed, the 
communication with the bowel closed, and drainage provided, if necessary. 

BIBLIOGRAPHY 

Beyea, H. D. : " The Elevation of the Stomach in Gastroptosis by the Surgical Plication 

of the Gastrohepatic and Gastrophrenic Ligaments." Phila. Med. Jour., 1903. 
Clark, J. G. : " Anatomical Considerations in Peritoneal Adhesions." Trans. Amer. Gyn. 

Soc, 1909, 401 ; Ibid. : " The Surgical Consideration of Congenital and Developmental 

Defects Leading to Obstinate Constipation." Jour. Amer. Med. Asso., August 16, 1910, 

lv, 449- 
Coffey, R. C. : " The Principles Underlying the Surgical Treatment of Gastro-intestinal 

Stasis, Due to Causes Other Than Structural or Ulcerative Conditions." Surg., Gyn. 

and Obst., 1912, xv, 365 ; Ibid. : " The Significance of the Fixation of Certain Abdominal 

Organs in the Human Body." Trans. Sect. Obst., Gyn. and Abdom. Surg., A. M. A., 

1915, 205. 
Eastman, J. R. : " Colon Stasis." Trans. Sect. Obst., Gyn. and Abd. Surg., A. M. A., 

1914, 78. 
Frazier, Chas. H. : " The Recognition and Treatment of Lesions of the Right Iliac Fossa, 

Other than Appendicitis." Annals of Surgery, October, 1912. 
Horsley, J. S. : " Surgical Treatment of Intestinal Stasis." Trans. Sect. Obst., Gyn. and 

Abd. Surg., A. M. A., 1917, 228. 
Lathrop, W. : " Lipectomy and Umbilical Hernia." Trans. Sect. Obst., Gyn. and Abd. 

Surg., A. M. A., 1916, 263. 
Martin, F. H. : " Gymnastics and Other Mechanical Means in the Treatment of Visceral 

Prolapse and Its Complications." Trans. Amer. Gyn. Soc, 191 2, xxxvii, 133. 
Mayo, Wm. J. : "Diverticulitis of the Large Intestine." Trans. O., G. and A. S., J. A. M. A., 

1917, p. 216. 
Murphy, J. B. : Intestinal Surgery. Kelly-Noble, ii, xxxiv. Saunders, Phila., 1907. 
Reed, C. A. L. : "The Redundant Sigmoid." Trans. Sect. Obst., Gyn. and Abd. Surg., 

A. M. A., 1914, 103 ; Ibid. : " Treatment of Constipation." Trans. Sect. Obst., Gyn. and 

Abd. Surg., A. M. A., 1916, 143 ; Ibid. : " Physiologic Colectomy." Trans. Sect. Obst., 

Gyn. and Abd. Surg., A. M. A., 191 7, 290. 
Smith, R. R. : " Enteroptosis." Surg., Gyn. and Obst., 1906, iii, 130. 
Tuttle, J. P. : " Relationship Between Rectal Disease and Those of the Female Pelvic 

Organs." Amer. Jour. Obst-, lxi, 784. 



CHAPTER XXVII 
DISEASES OF THE ANUS AND RECTUM 

FISSURE IN ANO 

Anal fissure is a crack or a linear ulcer of the mucous membrane 
on the margin of or within the sphincter ani muscle. It is produced 
by chronic constipation with straining at stool, and the passage of 
hard, scybalous masses that lacerate or abrade the mucous membrane. 
Small particles of fecal matter lodge in these abrasions or cracks, and are 
retained there for a time by reason of the infrequent action of the bowels. 
The sphincter muscles become irritated and spastic, so that they grasp the 
mucosa closely and further enclose the particles of foreign matter. Sooner 
or later the small abrasion or crack becomes a linear ulcer, which shows no 
tendency to heal. Since, by reason of the spastic sphincter, the walls are 
kept constantly in contact, there is no drainage and the condition pro- 
gresses from bad to worse. The base of the fissure may become inflamed,* 
and infiltration and induration of the parts beneath and on each side of it 
may take place. The ulcer may be small and linear and entirely concealed 
by the folds of the anal mucosa, or it may be larger and of an oval shape, 
so as plainly to be visible when the anus is exposed. Ulcers that are in- 
flamed and have their seat upon an inflammatory base are particularly evi- 
dent upon inspection. 

Fissure in ano is at times associated with a single mucocutaneous 
hemorrhoid, the latter probably being secondary to the former and caused 
by local blockage of the venous trunks by inflammatory products. The con- 
dition is predisposed to by dryness of the anal mucosa, and may exist in 
association with eczema of the anus. 

Although, as a rule, the ulcer is single, more than one may be present, 
but one is always more pronounced than the others. 

Symptoms. — The symptom characteristic of fissure in ano is pain dur- 
ing and after defecation. During defecation the anal folds are partially 
smoothed out by the passage of the fecal mass, the surface of the ulcer is 
irritated, and the patient complains of pain. Pain is most severe after defe- 
cation, when the sphincter contracts, holding the base of the ulcer tightly 
within its grasp, and compressing the recently irritated surface, covered 
with particles of fecal matter ; or the base of the ulcer may have been torn 
afresh during defecation. The stools often contain blood, and at times a 
thin, highly irritating discharge takes place from the anus, giving rise to 
intense itching — pruritus ani. The patient is usually constipated, and makes 
little effort to move the bowels systematically, avoiding the painful ordeal 
as long as possible. 

Diagnosis. — Pain during, but particularly just after, defecation, asso- 
ciated with bloody stools and constipation, is the symptom-complex strongly 
diagnostic of fissure. The latter may be detected at once on slightly sepa- 
rating the edges of the anus, or it can often be felt by the finger as a local- 
522 



DISEASES OF THE ANUS AND RECTUM 523 

ized point of induration and tenderness. A speculum may be introduced and 
the suspected area exposed. In some cases, however, the patient is so 
apprehensive, the sphincter is so tight, and examination causes so much 
pain, that the symptoms alone will justify the use of a general anaesthetic 
for a confirmation of the diagnosis, the treatment being carried out at the 
same time. 

Treatment. — The essential features of all methods of treatment are to 
clean the surface of the ulcer and to reduce or obviate the action of the 
sphincter. In mild cases the best results are obtained by cleansing the ulcer 
and the anal mucosa and keeping them clean, cauterizing the base of the 
ulcer, and overcoming the spasticity of the sphincter by performing gradual 
dilatation and by the application of a soothing ointment. Thus the fissure 
may be exposed through a speculum and thoroughly cauterized. A daily 
saline laxative should be prescribed and the patient instructed to wash the 
lower bowel thoroughly with repeated flushing of salt solution in the morn- 
ing after the bowels have moved. A sedative and astringent ointment, such 
as equal parts of unguentum gallae (U.S. P.) and unguentum stramonii (U.S.P.), 
should be applied by means of the forefinger, protected with a rubber finger-cot, 
the entire anal surface, external and internal, being gone over. The finger 
should be passed gently through both sphincters, using a boring motion. A 
daily treatment of this sort keeps the ulcer clean, lessens irritability of the 
sphincter, and hastens a cure. The patient should be instructed to use a 
soft washcloth or wet toilet paper after a bowel movement. When the 
case is of a severe type, the tenderness being marked, the sphincter very 
tight, or tjie ulcer old and indurated, an anaesthetic must be given and the 
sphincter either thoroughly divulsed or incised. 

Divulsion of the sphincter should be performed slowly, so as to over- 
stretch but not to rupture the muscle-fibers. The finger-tips of one hand 
should be so approximated as to form a cone, which should be well lubricated 
with sterile vaseline and inserted into the anus with a boring motion. This 
should be repeated until the muscle yields and sufficient dilatation has been 
secured to admit three fingers, one alongside of the other, without resist- 
ance. The muscle may also be stretched by inserting the forefinger or the 
thumb of each hand in the anus and gently pulling in opposite directions. 
Rough or forcible stretching of the sphincter may result in subcutaneous 
rupture, hsematoma formation, and, rarely, in permanent incompetency of 
the sphincter. 

Operation for Fissure In Ano. — Divulsion of the sphincter alone will 
suffice for the cure of mild cases of anal fissure. If, however, the ulcer is 
of considerable size and depth, or if induration is marked, it should be thor- 
oughly curetted, overhanging edges should be cut away, and the base should 
be touched lightly with pure phenol and alcohol. 

When the ulcer has become so chronic, or the case has proved so resist- 
ant to previous treatment, that division of the sphincter and total suspen- 
sion of its function for a time are regarded as necessary, then the sphincter 
muscle may be divided completely. The line of division should run through 
the base of the ulcer, at right angles to the muscle-fibers. The sphincter 
should always be divided at right angles. 



524 GYNECOLOGY 

FISTULA IN ANO 

Fistula in ano is a false passage or sinus between two or more of 
the following parts : The lower rectum, the anus, the perianal skin, 
and the cellular tissue of the ischiorectal fossae. The most common 
type takes the form of a fistulous channel between the anus and the peri- 
anal skin, the fistula beginning about the junction of the anus and rectum, 
passing externally to the sphincter muscles, through the cellular tissue of 
the ischiorectal fossae immediately alongside of the rectum, and opening on 
the skin surface surrounding the anal orifice. A blind anal fistula is a tract 
running between the ischiorectal fossae and the lower rectum or anus. The 
two varieties just described undergo many modifications, as regards both 
their relations to the anatomic parts involved and their extent. 

Fistula in ano has its origin in an abscess or a focus of suppuration in the 
cellular tissue surrounding the anus or lower rectum. Commonly an abra- 
sion or injury of the lower rectum or anus produces, by lymphatic absorp- 
tion, a suppurative focus in the cellular tissue. This burrows its way out- 
ward and finally discharges externally about the margins of the anus. The 
formation of the abscess and its rupture may be accompanied by violent or 
by barely noticeable manifestations. In other words, the patient presents 
the symptoms of an acute ischiorectal abscess, or all that may be remem- 
bered afterward is that a " boil " or some trivial inflammatory mass was 
present. Tuberculosis is believed to play an important role in the produc- 
tion of fistula in ano. A tuberculous erosion takes place in the lower rectum, 
which leads to infection of the neighboring cellular tissue, the tuberculous 
area breaks down, becomes secondarily infected, perhaps, with one of the 
varieties of intestinal bacteria, and then discharges externally or into the 
bowel, or in both directions, as the case may be. Before the pus or tuber- 
culous products find an exit the inflammatory process may have extended in 
various directions, following planes of fascia or cellular tissue. Occasion- 
ally the most extensive undermining and ramification of the inflammatory 
process take place before the external opening is formed. 

Of the influence of syphilis in the production of fistula, little positive 
information is available. Nearly all the cases of fistula attributed 
to syphilis have been secondary to stricture of the rectum. In such 
cases the fistula is usually a complicated or complex one, due to perfora- 
tion of the rectal wall by ulcerative processes and the subsequent in- 
fection of the perirectal tisues. The fistula, therefore, becomes one of 
simple infection, and not of a specific nature itself. The extent of the influ- 
ence of syphilis in the production of fistula is as yet undetermined, but 
there is no doubt as to the effect it has in delaying healing after operation. 

Because of the imperfect drainage that the external opening usually 
affords, or owing to the continuous entrance of gas or faeces from the 
bowel, or as a consequence of tuberculous or syphilitic processes in the 
areas affected, fistula in ano shows but little tendency to undergo spon- 
taneous cure. The inflammatory process along the line of the fistula 
may, therefore, continue gradually to extend, burrowing in one or 
more directions. 



DISEi\SES OF THE ANUS AND RECTUM 525 

Symptoms. — The most prominent symptom of a fistula in ano is an 
involuntary discharge of gas or liquid faeces and pus through the external 
opening. In the case of a blind internal fistula this does not, of course, 
occur. Other symptoms are repeated attacks of pain, swelling, and tender- 
ness in the affected regions, followed by the discharge of pus externally or 
from the bowel, and the subsidence of symptoms. Between these exacerbations 
the patient may be quite comfortable, the only manifestation being a constant 
moisture about the anus, or a feeling of weight or heaviness in the perineum, 
with painful defecation and the presence of blood and pus in the stools. 

Diagnosis. — The external opening of a fistula is usually readily dis- 
cerned, but it may be so small as to be demonstrable as an opening only by 
the passage of a fine probe. As a rule, a discolored spot or indurated ele- 
vated area marks the site of the opening. The site of the internal opening 
can often be detected by the induration surrounding it, but the only proof 
is the passage of a probe entirely through the fistulous tract. The internal 
orifice of a blind fistula may be exposed by means of a rectal speculum and 
a small laryngoscopic mirror. 

When the existence of a blind internal fistula is suspected, even though 
no internal opening can be felt or seen, the anal and the rectal crypts should 
gently but systematically be examined with a fine probe. In this way small 
Jistulae may be discovered that would otherwise escape detection. 

Treatment. — An effort at cure may be made by insuring daily evacua- 
tion of the bowels, irrigation, gradual dilatation of the sphincter, and re- 
peated and systematic cleansing of the fistulous tract, but, as a rule, 
recourse must be had to operation. 

The oldest method of operative intervention was to thread the fistulous 
tract upon a grooved director, bring the extremity of the director through 
the anus, and divide the overlying tissues, cutting the sphincter as it lay in 
the path of the knife. The fistulous tract, laid bare, was then thoroughly 
curetted, cauterized with pure phenol and alcohol, and allowed to heal 
by granulation. At the present time such a method should be reserved only 
for the worst cases, i.e., those in which the undermining and burrowing have 
been so extensive that copious drainage is the prime object of the operation. 

The ideal method in the majority of cases is excision of the fistulous 
tract, followed by immediate closure of the wound (see Fig. 435). This is 
usually feasible with suitable preparatory treatment of the fistulous tract. 
The treatment consists of dilatation of the external opening to secure free 
drainage, daily irrigation and thorough cleansing, and the application or in- 
jection of antiseptic solutions (iodine, 5 per cent.; ichthyol, 10 to 25 per 
cent., etc.). 

Just before the operation is begun, the fistula should be thoroughly 
cleansed and disinfected with hydrogen peroxide and tincture of iodine. 
The sinus is threaded upon a silver probe and the entire tract extirpated 
from the surrounding healthy tissue (Fig. 435). It may be necessary to divide 
the sphincter, but this may be done with impunity at right angles to the 
fibers. The wound after excision may at once be repaired with catgut 
sutures. If the sphincter has been divided, the ends must be aporoximated 
by two special sutures of fine chromic gut. 



526 



GYNECOLOGY 



When there are several or many ramifications of the fistula, all running- 
in the same general direction, and if the tracts may be excised without 
great loss of tissue, a single division of the sphincter may be sufficient, and 
immediate repair may be successfully carried out. If the wound is very 



. 





/\+-T - 



I I I \ 



.V* 



Fig. 435. — Excision of fistula in ano. 



extensive and it is evident that healing must take place by granulation, the 
incision in the rectal wall and mucosa and in the sphincter may be closed, 
and free drainage provided externally. Care should be taken, however, 
to stretch the muscle thoroughly, otherwise its contraction may interfere 
with the healing of the wound. 






DISEASES OF THE ANUS AND RECTUM 527 

PRURITUS ANI 

Pruritus about the anus may be produced by an irritating discharge 
from the bladder, vagina, or rectum, as in diabetes, leucorrhcea, fis- 
sure, fistula, proctitis, or rectal neoplasm. It may also be caused by 
eczema or other skin diseases affecting the anal mucosa and integument. 
Intestinal parasites (pin-worms), constipation, gout, nervousness, and habit 
may be factors in its production. It is prone to occur in stout, full-blooded, 
well-nourished women. 

Symptoms. — Intense itching, with an almost uncontrollable desire to 
scratch, is the chief symptom. The itching is most intense at night. The 
bowels are usually constipated. If fissure, fistula, or hemorrhoids coexist, 
blood and mucus appear in the stools. 

Diagnosis. — Since pruritus is but a symptom of several diseases, it has 
no subjective diagnostic signs of its own. 

Pruritus ani deserves individual consideration only when no gross lesion 
can be found to explain it. In these cases the cause is probably neurotic, and 
the local manifestations are more often the effect of the scratching than the 
cause of the itching. It may, of course, be quite impossible to distinguish 
between the two. 

The skin usually appears thickened, excoriated, and broken here and 
there by scratch marks ; the surface is either dry and scaly or moist 
and foetid. 

Treatment. — The aim of the treatment is the cure or alleviation of the 
underlying provocative cause. What has been said relative to pruritus 
vulvae is applicable here (see Chapter XI, page 170). 

HEMORRHOIDS 

Hemorrhoids are vascular tumors composed of dilated veins of the 
hemorrhoidal plexus, surrounded by the overstretched and hypertro- 
phied mucous membrane or skin of the lower rectum and anus. In 
women they may be due to the congestion of the hemorrhoidal plexus 
that takes place in those who follow sedentary occupations and suffer from 
constipation. The pressure of the child's head in the later months of preg- 
nancy is another factor, whereas the distortion and injury to the lower 
rectum and anus incident to labor almost invariably aggravate the ten- 
dency. Relaxation of the vaginal outlet and the pelvic floor is frequently 
accompanied by hemorrhoids. 

According to their location, hemorrhoids are designated as external 
when they protrude from the margin of the anus, and as internal when they 
lie within the grasp of or above the external sphincter and appear only on 
straining. They may be covered entirely by mucous membrane. Usually 
they are situated at the junction of the mucous membrane and skin, so that 
toward the lumen of the rectum they are covered by mucous membrane, 
whereas toward the perianal region the covering is cutaneous. 

Symptoms. — The symptoms of hemorrhoids are pain and bleeding after 
defecation, and a feeling of weight and protrusion about the anus. There 
may be considerable itching. Other symptoms dependent upon complica- 



528 GYNECOLOGY 

tions at times occur, the most common of which are thrombosis and inflam- 
mation of the hemorrhoidal masses. 

A thrombotic hemorrhoid is tense and painful, and generally protrudes 
from the anus, so that its pedicle or base lies within the grasp of the 
sphincter. In addition to the constant pain and tenderness of the swollen 
hemorrhoidal tumor there are severe pain on defecation and painful spasm 
of the sphincter muscle. Thrombosis may affect one or the entire group of 
hemorrhoids. The attack subsides in from three to ten days, the clot soft- 
ening and tension being relieved. The hemorrhoid may remain somewhat 
enlarged. Occasionally the clot may not be entirely absorbed, but may 
remain as a small, hard thrombus or vein stone. 

A hemorrhoid may also become infected and inflamed. These complica- 
tions are often associated with fissure or fistula. The tumor becomes 
slightly enlarged, may be more or less surrounded by inflammatory infiltrate, 
and is tender and painful. 

Diagnosis. — Cutaneous and mucocutaneous hemorrhoids are readily 
diagnosed by simple inspection while the patient is told to bear down. 
Hemorrhoids within the sphincter are visible often only after evacua- 
tion of the lower bowel and the introduction of a short proctoscope, or they 
may be made to protrude by having the patient assume a squatting posi- 
tion, bear down, and strain over a vessel of hot water. A thrombotic hemor- 
rhoid is tense, hard, exquisitely tender, and bluish in color. Thrombotic and 
inflamed hemorrhoids can be felt as well as seen, but an internal hemorrhoid 
that is neither thrombosed nor inflamed may escape recognition by the 
palpating finger. 

Treatment. — The cure of hemorrhoids is best and most surely accom- 
plished by operation. Some cases of moderate or mild degree may be ren- 
dered comfortable by non-operative methods of treatment. These include 
the administration of a daily laxative, irrigation of the lower bowel with salt 
solution, the use of the bidet, cold water enemas, and the exhibition of an 
astringent and sedative ointment 1 or suppository. 2 As contributing factors 
to successful treatment may be mentioned improvement of the general cir- 
culation by cardiac stimulants, replacement of a prolapsed or retroverted 
uterus, and the use of a pessary to correct a retrocele. A thrombotic 
hemorrhoid that is outside the grasp of the sphincter should be incised and 
the clot turned out. This can usually be done under local anaesthesia, but 

1 R. Ung. gallse. 

Ung. stramonii (U. S. P.) aa 
M. et ft. ung. 

Sig. : Apply locally as directed. 



Ext. stramon. 


gr. y 2 


Ac. tannic, 


gr. y 2 


Plumbi carbonat. 


gr. i 


Sol. plumbi acetat. dil. 


TU 2 


Creosot. 


ffi y 2 


M. et ft. suppository No. 


i. 



Sig. : Insert one at night. 



DISEASES OF THE ANUS AND RECTUM 



529 



in some cases, when the pain is very severe, general anaesthesia may 
be necessary. 

Inflamed hemorrhoids should be treated by the application of soothing 
lotions, either cold or hot, whichever gives most relief. Hot or cold solu- 
tions of dilute alcohol, lead-water and laudanum, or witch-hazel are favorite 
remedies. An injection of warm olive oil (i to 4 drams) with laudanum (5 
to 10 drops), administered through a small, soft-rubber catheter or a soft- 
rubber ear syringe, will often be prompt in its results. An opium and bella- 
donna suppository may be effectual. 

The operative treatment of hemorrohids consists in removal of the 
growths by excision or ligation. The former is the preferable method and 




Fig. 436. — Removal of hemorrhoids by clamp and cautery. 



may be accomplished in a number of ways. The clamp and cautery method 
is rapid, the danger of infection is reduced to a minimum, sloughing is in- 
considerable, and the pain is not as severe as when the hemorrhoid is ligated 
or when sutures are employed. The technic is as follows : 

After divulsion of the sphincter, the hemorrhoids usually are well ex- 
posed. As they project from the anal margin they divide into several 
groups. Each group in turn is subjected to the following plan of treatment : 
The tip is caught with a blunt hemostat, and traction is made upon it. The 
skin in the peripheral aspect is divided by a V-shaped incision, the base 
being directed toward the anus. When the mucous membrane is reached, 
the incision is continued into the membrane, completing the base of the V, 
which runs parallel to the rim of the anus. The skin and mucous mem- 
34 



530 



GYNECOLOGY 



brane above the incision are now pushed away by blunt dissection, and a 
hemorrhoid clamp placed along the raw area thus exposed, the heel of the 
clamp pointing toward the lumen of the gut. The clamp is tightly closed, 
and the projecting hemorrhoidal mass cut away with scissors at a point 
about one-eighth of an inch from the surface of the clamp. The remaining 
tissue beyond the clamp is now cauterized until it is thoroughly charred. 
Upon removing the clamp a charred ribbon of tissue is found extending in a 
radial direction from the anus outward along the path of excision (Fig. 436). 
Bleeding seldom follows the operation if the clamp is properly placed, 
i.e., with the heel pointing toward the gut, so that the greatest amount of 
pressure is exerted upon the source of the most active blood supply, and if 
the charred area of tissue projects a little from the surface of the clamp and 
has not been burned off flush with its surface. A narrow strip of drainage 
gauze thickly coated with sterile vaseline is now introduced within the 




Fig. 437. — Moschcowitz s conception of 

prolapse of rectum; incipient prolapse. 

(.Courtesy Surgery, Gynecology and 

Obstetrics. 



■~-~-Partial prolapi. 
of rectum 



Fig. 438. — Moschcowitz's conception of 

prolapse of rectum; partial prolapse. 

Courtes}' Surgery, Gynecology and 

Obstetrics. 1 ) 



rectum. This will serve to direct attention immediately to any hemorrhage 
that may take place within the bowel. This strip is removed at the end of 
five days, when the bowels are opened with castor-oil. 



PROLAPSE OF THE RECTUM 

Prolapse of the rectum not infrequently occurs in connection with 
extensive prolapse of the uterus or with marked relaxation of the 
vaginal outlet with rectocele. It is then a part of a general relaxation 
and loss of supporting power of the muscles and fascia of the pelvic 
floor. Prolapse may affect the mucosa alone (partial prolapse) or the entire 
wall of the rectum (complete prolapse). The predisposing causes of rectal 
prolapse are multiple childbirth and consequent injuries to the pelvic floor, 
relaxation of the sphincter muscles of the anus from paralysis, exhausting 
diseases, injury to the sacral plexus-, etc. Straining at stool, as in some cases 
of rectocele, urethral obstruction, chronic constipation, and chronic diarrhoea, 
is a prolific source of prolapse. Tumors of the lower bowel, hemorrhoids, 
polyps, etc., which drag upon the mucous membrane, are occasional causes. 



DISEASES OF THE ANUS AND RECTUM 



531 



Abnormal and possibly congenital elongation of the mesosigmoid and meso- 
rectum are said to be among the provocative lesions. 

According to Moschcowitz and Jones, many of the so-called prolapses of 
the rectum are in reality hernias (Figs. 437 to 440). The anterior wall of 
the rectum is pushed through the anus by the hernial contents, and the sac 
of the hernia is a prolongation or a deepening of the peritoneal cul-de-sac. 
known in the female as the pouch of Douglas. 3 The usual contents of the 
hernia is small bowel. Defects in the transversalis fascia, known as the 
pelvic fascia in this region, with which the peritoneum is so intimately 
related, are uniformly present and may be either congenital or acquired. 
This conception of the subject which unquestionably is correct, applies to all 
cases except those of simple prolapse of the rectal mucosa. 

Symptoms. — The symptoms depend on the degree of prolapse that is 
present. In early cases there may be no subjective symptoms. In well- 



'Periloneum. 



Rsciun 




Fig. 439. — Moschcowitz's conception of 

prolapse of rectum; incomplete prolapse. 

'Courtesy Surgery, Gynecology and 

Obstetrics.) 



Fig. 440. — Moschcowitz's conception of 
prolapse of rectum: complete prolapse. 



marked cases there are irregular and unsatisfactory bowel movements, a 
sensation as if the movement was incomplete, pain and discomfort about the 
anus, partial or total incontinence of flatus and faeces, discharge of mucus 
and blood, and the protrusion of the inverted rectum, either constantly or 
upon attempts at defecation. 



3 There are three varieties of deep cul-de-sac: 

First: The cul-de-sac may be very deep congenitally. The rectum and the bladder 
appear flattened against the pelvic walls and the peritoneal lining of the deep pelvis 
is smooth and adheres closely to the pelvic walls. In this type the fascia is exceedingly 
weak, and the weight of the intestine causes rectal and vaginal protrusions. To this 
group belongs virginal prolapse. 

Secondly: The cul-de-sac becomes very deep in multipara with lacerated perineums ; 
the peritoneum is redundant, but not densely adherent to the pelvic wall or to the 
pelvic organs. The fascia, although torn, is still able to support certain of the pelvic 
structures, and the peritoneum also acts as a suspensory support to the vagina and 
the rectum. Although this anatomic peculiarity is frequent in multiparas, prolapse of 
the uterus and large rectocele are relatively infrequent. 

Thirdly: Another and rare type is seen in which there is an opening in the fascia 
between the vagina and the rectum, extending from the posterior cul-de-sac to the 
levator muscles, and accompanied with a vaginal protrusion that is somewhat analogous 
anatomically to an inguinal hernia. 



532 GYNECOLOGY 

Diagnosis. — The diagnosis of rectal prolapse is readily made by inspec- 
tion of the anus while the patient is in the dorsosacral or in the squatting 
position and attempting to defecate. Further examination is required to de- 
termine whether the mucosa alone or the entire rectal wall is involved. 

Treatment. — Prolapse of the rectal mucosa may be treated by linear 
cauterization or by excision of the prolapsed part. In conjunction there- 
with, the rectal wall may be supported by a slight modification of the ordi- 
nary operation done for rectocele, a condition with which prolapse of the 
rectal mucosa is frequently associated. When this plan is adopted, the an- 
terior wall of the rectum should be freely exposed after division of the 
posterior vaginal wall. The rectum should be freed from its surrounding 
attachments, above the level of the levator ani, and sutures introduced in 
two directions so as to shorten the rectum, as well as to narrow its lumen. 4 
Whatever method of posterior colporrhaphy is contemplated may now be carried 
out and completed in the usual manner. In mild cases, all that may be necessary 
is to make a long incision through the posterior vaginal wall, extending well 
up toward the cervix, separate the rectum from the surrounding tissues, and 
fix it at as high a level as possible, by means of sutures that embrace the 
upper angle of the posterior vaginal incision, the pelvic fascia, and rectal 
wall. These are continued downwards at intervals, the lowermost approxi- 
mating the fibers of the levator ani. 

The basis of the operative treatment suggested by Moschcowitz and 
Jones consists in obliteration of the posterior cul-de-sac. This throws the 
weight of the intestine against the uterus, broad ligaments, bladder, and 
symphysis, just the opposite to the condition that obtains with an open 
deep cul-de-sac. In the latter case the weight of the intestines is thrown on 
the anterior rectal and the posterior vaginal wall. 

Moschcowitz, in closing the cul-de-sac, inserts purse-string sutures from 
below upward, tying each one as it is completed (Fig. 441). He passes the 
sutures through the serous coat of the bowel, and when he reaches the 
supravaginal cervix and the uterus, he includes them. He directs that one 
must carefully avoid the internal iliac vessels, which can be recognized by 
palpation, and the ureters, which may be located by catheterization, if this 
is required. In aged women fixation of the uterus may be done in connec- 
tion with the other operation. It is not necessary to suspend the sigmoid. 
Usually the bowels move of their own accord in less than a week. As a rule, 
catheterization is necessary. 

TUMORS OF THE RECTUM ' 

New growths of the rectum may spring from muscle, connective tissue, 
or mucosa. Among those most frequently encountered, therefore, are 
adenoma, papilloma, myoma, fibroma, myxoma, sarcoma, and carcinoma, 
although teratomata are also found at times. 

4 Such sutures may be passed also after the method of Lane, i.e.-, through an incision 
from the lower end of the sacrum to the anus. The coccyx is removed, exposing the 
posterior rectal wall, catgut sutures are passed through the muscular coat in the long axis 
of the gut for a distance that corresponds to the requisite amount of shortening. After 
the longitudinal sutures are tied, interrupted transverse sutures are passed that approximate 
the lateral walls of the rectum and narrow the lumen of the gut. 



DISEASES OF THE ANUS AND RECTUM 



533 



POLYPS 

Benign rectal growths are frequently pedunculated, when they are 
known as polyps. The most common form seen in children is formed by 
hypertrophy of a solitary follicle. The surface is covered by epithelium and 
the connective tissue is myxomatous. Other forms of rectal polyp are 
adenoma, papilloma, fibroma, and lipoma. Polypoid adenomata and papil- 
lomata are most often seen in adults. Adenoma is most often multiple, and 
is said to recur. When multiple the individual tumors vary in size, form, 
and appearance. Instead of being polypoid, they may have a broad base 
of attachment. The sigmoid and the colon may be involved coincidentally. 
The tumors are prone ultimately to undergo malignant degeneration. 

Symptoms. — The occa- 
sional presence of mucus and 
blood in the stools may be the 
only indication of a polyp if 
the growth occupies a position 
well above the sphincter. 
Active symptoms appear only 
when the polyp comes down 
within the grasp of the 
sphincter, when there is a 
sensation of fullness, a fre- 
quent desire to defecate, 
spasm of the sphincter, and 
mucous and bloody discharge 
from the rectum. 

Diagnosis. — The diagnosis 
can be made by inspection or 
by digital examination. The 
differentiation of benign hy- 
pertrophied follicles, adeno- 
mata, and papillomata from j 

mallPfnant PTOWtllS Of Similar ^ on ^ or cure °^ P r °l a P se of rectum by obliterating cul-de-sac of 
& . s Douglas. 

form is made partly from the 

fact that there is no induration at the point of their insertion into the 

mucous membrane. 

Treatment. — The treatment consists in snaring the pedicle, if the tumor is 
high, or in crushing the pedicle with a clamp and division by a cautery knife, if 
the tumor is low. If the tumor is attached broadly to the bowel, after 
excising the base down to the muscular coat, the edges of the mucosa 
should be brought together with sutures. If the pedicle is at such a 
height that invagination of the peritoneum therein is possible, the pedicle 
should be securely tied. 

Medicinal treatment of multiple adenomata is of little value, and even 
surgical treatment is likely to prove unsatisfactory. If malignant degenera- 
tion takes place, complete extirpation of the affected parts holds out the 
only hope for cure. In some cases the involvement may be so extensive as 
to make removal impossible. 




534 GYNECOLOGY 



CARCINOMA OF THE RECTUM 



Carcinoma may involve the anal, the extraperitoneal, and the intra- 
peritoneal portions of the rectum, as well as the sigmoid. More than 
half of all rectal carcinomata involve the intraperitoneal portion, and 10 
per cent, are confined to the anal part. About the anus the most frequent 
variety seen is epithelioma ; above that point adenocarcinoma is the rule. 

Etiology. — Cancer of the rectum is less common in women (40 per cent.) 
than in men (60 per cent.). Other diseases of the rectum, such as multiple 
polyps, adenomata, and mucous colitis, frequently precede cancer. 

Symptoms. — There are no characteristic symptoms in the earliest stage. 
Vague pain in the sacral region, with increasing constipation or a tendency 
to diarrhoea and slight digestive disturbance, may be the first indications. 
Later on loss of weight, pain in the rectum, and the discharge of mucus and 
blood from the anus appear. 

When carcinoma develops secondarily, the symptoms of the primary 
condition, of course, precede it. 

Diagnosis. — Every patient with symptoms suggestive of malignant dis- 
ease demands a digital examination of the lower bowel and a proctoscopic 
and a sigmoidoscopic examination of the upper rectum and sigmoid flexure. 

In the earliest stages, carcinomata appear as plaque-like, slightly mov- 
able deposits beneath the mucosa. The underlying mucosa is congested, 
thickened, and smoother than normal. In some varieties small papillary 
excrescences, connected with the mucous and submucous tissues by an in- 
durated base, are seen. Early scirrhus cancer may appear in the form of 
an annular deposit in the submucosa, closely resembling a fibrous stricture. 

A microscopic examination should always be made in order to distin- 
guish between benign and malignant conditions if it is easy to obtain tissue 
for this purpose through the proctoscope ; otherwise the clinical findings may 
be accepted as conclusive and treatment advised accordingly. Exploratory 
celiotomy may be indicated in growths situated high up. 

Treatment. — The only hope of cure lies in early extirpation of the dis- 
eased portion of the bowel with a surrounding border of healthy tissue. The 
one exception to this statement is found in cases of epithelioma of the anus — 
here radium may be effectual (see Radium and Rontgen Ray Therapy. 
Chapter XL). Very early epithelioma may be treated also by local excision 
or destruction with the cautery. Epithelioma and adenocarcinoma of the 
lower bowel require total extirpation of the diseased bowel, including the 
anus ; the inguinal lymphatics also should be removed. The technic of 
Cripps or Kraske may be selected. 

Operation for cancer of the second and third portions of the rectum and 
the recto-sigmoid should be performed in two stages. In the first, the 
abdomen is opened, a thorough exploration is made of the lymph-glands, 
liver, etc., and in favorable cases the diseased area of the bowel is excised. 
If the line of division below leaves a half inch or more of peritoneum-cov- 
ered bowel and the length of bowel resected is not too great, an end-to-end 
tube anastomosis may be performed between the proximal and the 
distal ends. 

If the rectum is so extensively involved that complete extirpation is re- 






DISEASES OF THE ANUS AND RECTUM 535 

quired, the sigmoid should be divided above the growth and the proximal 
end implanted into the abdominal wall so as to form a new anus. The dis- 
eased area is then separated by ligation of its mesenteric attachments and 
the distal end turned in and pushed down into the pelvis with the growth. 
The pelvis is then excluded from the peritoneal cavity by peritoneal suture, 
utilizing the back of the bladder, the uterus, the broad ligaments, and any 
peritoneal folds that are available. After six days a perineal incision is 
made and a Kraske resection of the lower sacrum with removal of the recto- 
sigmoid and rectum, including the anus, is performed. 

For the technic of these operations the reader should consult the writ- 
ings of Cripps and Charles Mayo. 

STRICTURE OF THE RECTUM 

Stricture of the rectum may be annular, valvular, tubular, or linear. 
Strictures may be due to congenital malformations or acquired lesions. 
They may be spasmodic or organic in nature. Acquired organic 
strictures are due to neoplasms growing into and contracting the rectal 
walls, to destructive lesions of the submucosa (tuberculous, syphilitic, 
dysenteric ulcerations, traumatism, perirectal abscess, etc.), and to inflam- 
matory lesions of the surrounding tissues that extend into and compress or 
constrict the gut. 

Symptoms. — The symptoms consist in gradually increasing and persist- 
ent constipation, alternating or combined at times with diarrhoea. The 
latter results from the irritation of hard fecal masses retained above the 
point of obstruction. Later fecal concretions may be felt in the sigmoid 
and colon. Anorexia, foul breath, coated tongue, skin eruptions, and other 
evidences of intestinal intoxication are present. In the severe forms mucus 
and blood are found in the stools. 

Diagnosis. — When the stricture is within a finger's length of the anus, 
the diagnosis is made without difficulty. In strictures higher up, the pneu- 
matic proctoscope and sigmoidoscope are the most valuable aids to diag- 
nosis, but exploratory celiotomy may be required in some cases. 

Treatment.— A nutritious mixed diet should be ordered. Milk produces 
hard faeces and is unsuitable in these cases. Powerful purgatives should be 
avoided, but laxatives may be taken regularly. Of the latter, the best is 
olive oil or one of the refined paraffine oils, taken several times daily. 

Although not often curative, gradual dilatation is the most used and most 
satisfactory method of treatment. 

BIBLIOGRAPHY 

Brettauer, J. : " The Rectum and Bowel in Their Relation to Pelvic Disease." Amer. Jour. 

Obst, ixi, yyy. 
Cripps, W. H. : Diseases of the Rectum and Anus. London, Churchill, 1907. 
Jones : " Relation of the Deep Cul-De-Sac to Prolapse of the Rectum and Uterus and 

to Rectocele." Post. Med. and Surg. Jour., 1916, clxxv, 623. 
Lynch, J. M. : Diseases of the Rectum and Colon and Their Surgical Treatment. Phila- 
delphia, Lea, 1914. 
Mayo, C. H. : " The Choice of Operative Procedure in Cancer of the Rectum and Pelvic 

Colon." Annals Surg., 1917, lxv, 129. 
Moschcowitz, A. V. : " The Pathogenesis, Anatomy and Cure of Prolapse of the Rectum.'' 

Surg., Gynec. and Obst., 1912, xv, 7. 
Murphy, J. B. : Intestinal Surgery, Chapter xxiv, in Kelly and Xoble, Gynecology and 

Abdominal Surgery, vol. ii. Philadelphia, Saunders, 1907 ; Ibid. : " Resection of the 

Rectum per Vaginam." Phila. Med. Jour., 1901, vii. 
Tuttle, J. F„ : " The Relationship Between Rectal Diseases and Those of the Female 

Pelvic Organs." Amer. Jour. Obst., 1911, lxi, 784. 



CHAPTER XXVIII 
BACKACHE 

Backache may be indicative of abdominal or pelvic disease, as well as 
of disorders of the bones, muscles, and joints of the lower abdomen, back, 
and thighs. The reason for it may be at once apparent — a quickly ascer- 
tained cause and effect — and the treatment obvious, or, in spite of careful 
search, no definite cause may be found. Not infrequently backache has 
been ascribed to abdominal or pelvic disorders, and yet, when the latter 
were corrected, the pain persisted and the patient did not improve. Atten- 
tion has then been directed to those disorders of the constituent structures 
of the parts which are well known, such as spinal curvature, hip-joint dis- 
ease, disproportionate length of the lower extremities, tuberculosis of the 
vertebrae or the sacroiliac joints, hypertrophic arthritis (spondylitis defor- 
mans), Charcot's spine, and spinal injuries. If, upon careful examination, 
none of these was found, the symptoms were spoken of as rheumatic or 
gouty, and finally, when appropriate treatment did not bring relief, the con- 
dition was given up as hysteric or neurasthenic. All of which is mentioned 
here to preface the statement that certain factors that are operative in the 
production of backache may easily be overlooked. It is to these that atten- 
tion has been drawn by the work of Reynolds, Lovett, Dickinson, Gold- 
thwaite, Truslow and others. 

The first is the constant demand that is made upon certain muscle 
groups and joints in the maintenance of equilibrium. 

The assumption of the erect posture without conscious effort depends 
upon the maintenance of equilibrium. 1 In the normal erect posture 
(Fig. 442), maintained without conscious effort, a vertical line drawn 
through the center of gravity of the body must drop within a trapezoid 
formed by the outer borders of the feet and imaginary lines con- 
necting the tips of the toes and the back of the heels. The supporting 
structures are the arches of the feet, secured by their pillars, the heel 
bones, and the heads of the metatarsal bones. The line of the center of 
gravity, when the body is in a state of perfect equilibrium, coincides with a 
plane that would cut the occipito-atlantoid joint, a portion of the cervical, 
thoracic, and lumbar vetebrse, the pelvis between the anterior spine and the 
anterior rim of the acetabulum, the knee-joint near the patella, and the foot 
near the tarsometatarsal junction, these relationships being altered in 

1 Both lateral and anteroposterior equilibrium must be maintained. Lateral equilibrium 
is easily maintained by placing the feet nearer together or further apart : disturbance in 
lateral equilibrium is associated with well-marked orthopedic deformities (spinal curvature, 
tilted pelvis, shortened leg). These are readily recognized, their significance is well under- 
stood, and the treatment has been well established, so that they need not be discussed here 
further than to say that disturbance of lateral may complicate or precede disturbance in 
anteroposterior equilibrium. They must always be looked for and corrected when found. 
We are concerned here chiefly with the less easily recognized, less easily cured, and less 
generally appreciated defects in anteroposterior equilibrium. 
536 



BACKACHE 



537 



accordance with the anatomic peculiarities of the individual. If the equi- 
librium is to be maintained, projection of a part of the body in front of this 
line must be compensated for by projection of another part back of the 
line. In the normal erect posture, the parts in front of the line of the 
center of gravity are equal to those back of it, except where muscular stress 
exerted on adjacent parts compensates the overbalance. Some of the joints 
permit forward, and some backward, bending, some both, the limitation in 
one direction or the other being due to the arrangement of 
the ligamentous or bony features. 2 

When the body is erect and perfect equilibrium is main- 
tained, the line of the center of gravity runs through or near 
to all the points of anteroposterior movement, and the effort 
of the muscles and ligaments anterior to the line is equal to the 
effort of those posterior to the line; none are too greatly taxed; 
none too seldom called upon. When the center of gravity is 
displaced forward, the posterior muscle and ligament groups 
must perform extra work ; when it is displaced backward 
(rare), the anterior muscle and ligament groups are under 
increased stress. 

The joints that are especially concerned in the mainte- 
nance of equilibrium are the vertebral, the lumbosacral, the 
sacroiliac, and the tarsometatarsal. These are the joints of 
limited motion, and are subjected to greater strain than are 
the hip-, knee-, and ankle-joints. 

The vertebral and lumbosacral joints are supplied with 
very strong ligaments and are well splinted by muscles. The 
sacroiliac and the tarsometatarsal joints are those subjected 
to the greatest strain and are those that have the least natural 
protection. The sacroiliac joint connects the trunk and the 
pelvis; in the erect, in the sitting, and even, but to a much 
less degree, in the supine position, this joint is subject to 
stress. It is dependent for endurance upon the relation of the 
articulating surfaces of the sacrum to those of the innominate 
bones, and the strength of its cartilaginous and ligamentous 
attachments. It is not splinted or reinforced, except to a very 
limited extent, by muscles or tendons passing over it. The 
weight of the trunk transmitted through the spine may carry 
the promontory slightly downward and forward into the 
pelvis, the sacrum rotating on a transverse axis' passing 
through the second piece. 

The arches of the feet, which bear the weight of the entire body in the 
erect position, depend for their strength essentially upon the ligamentous 
attachments between the calcaneum, cuboid, external cuneiform, and third 
metatarsal bone. In addition they are reinforced bv the tendons of the 



Fig. 442. — Nor- 
mal posture. 
(After Dickinson 
and Truslow.) 



Thus the chin falls forward, but backward bending of the head is limited by the occi- 
put : the trunk bends forward to more than right angles on the thighs, but only slightlv 
backward by virtue of the iliofemoral ligaments ; the knees can be flexed, but not bent 
forward ; the ankles can be more extended than flexed. 



538 GYNECOLOGY 

peroneus longus and the tibialis posticus muscles. To these may be added 
the plantar fascia and the muscles to the toes arising from the calcaneum. 

In disturbances of equilibrium, either forward (usual) or backward (rare) 
displacement of the center of gravity, the vertebral, lumbosacral, sacro- 
iliac, and tarsometatarsal joints are placed under unusual stress. 

Excessive demands of this sort upon the muscles and joints give rise 
to irritability and fatigue of the muscles, and to congestion and relaxation 
of the joints, thus giving rise to a symptom-complex known as static backache. 

The second of the factors in the production of backache is the predisposi- 
tion in women to faulty development of the muscles, to joint sprains, and 
to incorrect postures. That a large proportion of women are deficient in 
muscular development in general needs no proof; this is due to their rela- 
tive inactivity after the age of puberty. This faulty muscular development 
is especially evident in the muscles of the back and abdomen, particularly 
in women who have worn corsets. 

The joints that women are prone most often to overtax and strain are 
the sacroiliac and the tarsometatarsal. The former may be injured during 
labor, while the arches of the feet may be weakened by the wearing of shoes 
that interfere with normal development. Excessive weight, out of all pro- 
portion to the muscular and bony development, is also a cause of fallen arches. 

Faulty postures in women may be due to the wearing of unsuitable 
corsets or shoes, weak muscles, developmental defects of the chest and ab- 
domen, pelvic and abdominal ptoses, pelvic inflammation, and obesity. 

A third factor to be considered in a study of backache of obscure origin 
is the effect of remote foci of infection upon the spine and the sacroiliac 
articulation. In individuals already exhibiting a strain or sprain of the 
joint a toxic arthritis usually attacks these parts. 

These remarks may serve to correlate the following conditions, which, 
for convenience, will be considered separately. 

STATIC BACKACHE 

Etiology. — Backache is known as static when it is caused by the fatigue or 
strain of certain groups of muscles and ligaments the result of excessive demand 
made upon them in order to maintain equilibrium. The disturbance of 
equilibrium usually consists in a displacement of the center of gravity for- 
ward, which throws an increased burden on the lower posterior group of 
muscles. Occasionally the center of gravity is displaced backward, and 
when this occurs the back muscles are strained above and the iliopsoas ante- 
riorly and below. Disturbance of lateral balance may occur in combination 
with disturbance of anteroposterior balance. 

Disturbances in equilibrium are due to the following causes : 

1. Flat-foot. — The. feet are pronated and the tarsus sinks to the ground. 
This results in changes and readjustments of the entire weight-bearing 
column, and may cause so marked a disturbance of balance as to produce 
severe backache, as well as pain in the feet, legs, and thighs. 

2. Pelvic disorders of an inflammatory nature that compel the woman to 
assume a forward position in order to ease sensitive pelvic parts. 



BACKACHE 



539 



Fig. 443. 



Fig. 444. 



3. Pelvic tumors, or excessive accumulations of fat in the abdomen or 
anterior abdominal wall, which, by their weight, lead the patient to assume 
a forward position. 

4. Relaxed and pendulous abdomen, often associated with displacements 
of the abdominal and pelvic organs or prolapse. 

5. Skeletal defects, such as knock-knees, difference in the length of the 
extremities, and defective articulation be- 
tween the vertebrae, usually between the fifth 
lumbar vertebra and the sacrum. 

6. Faulty posture, of which there are two 
varieties — first and most frequent, the " kan- 
garoo " type (Fig. 443), in which the center 
of gravity is displaced forward; secondly, the 
"gorilla" type (Fig. 444), in which the 
center of gravity is displaced backward. 
The kangaroo type of posture may be asso- 
ciated with — (a) the slumped, visceroptotic 
figure (Fig. 445), with shoulders drooping 
forward, narrow intercostal angle, long 
waist, and relaxed abdominal parietes ; (b) 
the " overfeminine figure" of Reynolds (Fig. 
446), trunk atrophy (corset pressure), small 
bones, narrow intercostal angle, slender, 
tapering waist, with broad and excessively 
padded hips, a deformity due to tight lacing 
and insufficient exercise. 

Symptoms. — The principal symptom is 
backache, which affects especially the lower 
lumbar and sacral region when the patient 
is erect. In severe cases it is more or less 
constant, but it may be intermittent in 
milder ones. The discomfort may be de- 
scribed as a feeling of extreme fatigue or an 
aching, dragging pain. Relief is not ob- 
tained by the recumbent posture alone, but 
the patient may have found that a certain 
position that relaxes the strained and 
fatigued parts gradually brings relief. 

The pain may be referred to the 
occipital and upper dorsal region. If 
there is an associated sacroiliac sprain, pain may be present in the coccygeal 
area and along the distribution of the great sciatic nerve. If the feet are 
pronated or flat, there is pain in the legs and feet. As a rule, the pain is 
bilateral, although one side may be more painful than the other. Tender- 
ness is often present over the sacroiliac joint, since in severe cases of static 
backache the faulty posture has put excessive strain on this articulation. 
Muscle spasm, either on one or on both sides, is always present in static 
backache. When static backache is unilateral, the sacroiliac joint of the 




443. — Kangaroo posture. (After 
Dickinson and Truslow." 
Fig. 444. — Gorilla posture. (After Dick- 
inson and Truslow.) 



540 



GYNECOLOGY 



affected side is especially likely to be tender and painful. There may be 
some limitation of motion, both laterally and anteroposteriorly, but this 
finding is not constant. 

Diagnosis. — In making a diagnosis of static backache the most pains- 
taking effort often is required. The patient must be examined systematic- 
ally, with special regard to the following : . 

(a) The attitude in general, whether bent forward (kangaroo), back- 
ward (gorilla), or normal. 

(b) Shoulders back and square or forward and round. 

(c) Abdomen rounded and pendulous, or well held up and flat. 

(d) Feet well arched or flat; shoes with high or low heels, roomy or tight. 

(e) Constriction of waist. 
(/) Width of buttocks. 

Preliminary observations may be made with the outer clothing re- 
moved, the patient standing clothed in corsets and shoes. A graphic method 



Fig. 446. 




Fig. 445. — Slumped visceroptotic figure. (After Smith.) 
Fig. 446. — Overfeminine figure. (After Reynolds.) 

of recording the posture (Dickinson) and the anteroposterior equilibrium is made 
by tracing the outlines of the patient upon a large sheet of paper hung upon the 
wall. The patient is directed to stand with the side to the wall, the backs 
of the heels touching a strip of wood fixed to the floor at right angles to the 
wall. A tracing is then made as shown in the illustration (Fig. 447). At 
this point in the examination the corset and shoes should be carefully in- 
spected (see page 543). The corset and shoes should then be removed and 
another tracing made. A comparison of the tracings, shows the normal 
attitude of the patient and the extent to which it has been modified by her 
dress, especially by her corsets and shoes. 

Normal Type. 3 — The head is level. The line of the dorsal spine is gently 

3 The following notes descriptive of the normal posture and of the two most frequent 
deviations have been modified from Truslow. 



BACKACHE 



541 



rounded and touches the " rear perpendicular.'' 4 The line of the lower dorsal 
and lumbar spines curves gently forward and then backward, the top 
directly above the bottom. The angle of the plane of the pelvic inlet is 
about 60 degrees with the horizon. The thighs and the legs, the hip-joint, 
and the knee-joints are in or adjacent to the plane of the center of gravity. 
with a proper balance maintained between the flexor and the extensor 
muscles, and therefore no strain. The body weight is well distributed be- 
tween the heels and the balls of the feet, and there is good control in walking. 

Kangaroo Type. — The head is prone to tilt 
upward. The shoulders are in front of the rear 
perpendicular. The lower dorsal and lumbar 
curves are less marked, and the line of the lower 
dorsal and lumbar spines slants downward and 
backward. The sacrum tends to rotate forward 
between the ilia, straining the sacroiliac joints, 
the erector spinae group of muscles are stretched 
and strained. The pelvis is rotated forward on 
the hip-joints, and the plane of the inlet is at an 
angle of more than 60 degrees. The line of the 
center of gravity is in front of the hip-joints, the 
ham-strings are stretched, the flexors are relaxed, 
the knees are displaced backward (extreme ex- 
tension), the center of gravity is in front of the 
joint, the extensor muscles of the leg are over- 
stretched, the flexors are relaxed, and the weight 
of the body is unequally distributed upon the 
feet, most of the strain falling on the balls 
and arches. 

Gorilla Type. — This type is much less fre- 
quent than the others mentioned. The head is 
prone to tilt downward, the shoulders are back 
of the rear perpendicular, and the line of the 
lower dorsal and lumbar spine is forward. The 
sacrum tends to rotate backward between the 
ilia, putting a strain on the joints. The iliopsoas _ 

r ° 1111 -1 1 FlG * 44 ? • — Patient s outline being 

muscles are stretched ; the abdominal muscles are traced. (After Dickinson and 
on tension. The pelvic inlet is at an angle of less 

than 60 degrees to the plane of the horizon. The center of gravity is back of the 
hip-joint; there is strain on the iliopsoas ligament and flexor groups of 
muscles. The knees are forward; the extensors of the feet are on tension; 
the weight of the body is borne especially by the heels, but in an effort to 
equalize the strain there is tension of the tendons of the extensor group 
of the legs. 

After determining the anteroposterior balance of the individual (center 
of gravity normal or displaced forward or backward), the examiner may 

4 A perpendicular line passing through the upper extremity of the gluteal crease. 





542 GYNECOLOGY 

devote his attention to a search for contributory causes of disturbances of 
the equilibrium. 

Chest Defects. — In women, with the notable exception of singers, ath- 
letes, and those who have not worn corsets, the epigastric angle is more 
acute than normal, and the lower part of the thorax is compressed from 
side to side. 

Muscular Development. — Almost all women, except those who have fol- 
lowed athletic pursuits and those who have avoided the use of corsets, show 
deficient development and lack of tone of the muscles. In women who have 
borne children this is most noticeable in the abdominal wall and back. 

Feet. — When the arches of the feet are flat, the tarsus sinks to the ground 
and the feet are pronated. This results in changes and readjustments in the 
entire weight-bearing column above, and may result in so marked a dis- 
turbance in balance as to produce pain in the feet, legs, and thighs, as well 
as backache. 

Constriction About the Waist. — Many women who wear corsets show 
narrowing of the lower thorax and constriction about the waist. Marked 
cases are invariably accompanied by visceroptosis, and pendulous abdomen 
and excessive fat pads are commonly associated. 

Fat Pads. — Normally, the layer of fat on the abdominal wall above the 
umbilicus should be thicker than the layer below it. In many women, as a 
consequence of corsets, the fat is thicker below the navel ; pads of fat are 
also present over the iliac crests, over the trochanters, and beneath the 
buttocks. These pads may vary in size from the rotundity of form con- 
sidered characteristic of the sex, to gross and fleshy protuberances and 
actual deformities. 

Differential Diagnosis.— Before a positive diagnosis of static backache 
can be made, the influence of existing pelvic and vertebral disorders must be 
ruled out. Pendulous abdomen, visceroptosis, and displacement of the pelvic 
viscera may precede or accompany postural defects. Pelvic disease of an inflam- 
matory nature may precede postural defects, the patient unconsciously leaning 
forward and relaxing the abdominal wall in order to lessen intra-abdominal ten- 
sion and relieve pressure on the sensitive viscera. Backache due to downward 
displacement of abdominal or pelvic viscera is usually promptly relieved by the 
recumbent posture, and even in the erect position the patient can be made com- 
fortable by the replacement and support of the affected structures. 

Backache due to pelvic disorders is usually most severe just before or 
during the menstrual period, and is often accompanied by bladder and rectal 
symptoms. When postural defects are accompanied by inflammatory or 
neoplastic disorders of the pelvis, it may be necessary to cure the pelvic 
disease before one can determine how much of the pain is pelvic and how 
much is static in origin. Structural and organic disease of the spine should 
not be difficult to recognize. In Pott's disease and following injuries, the 
back pain is definitely localized. Referred pain, due to pressure on the 
posterior roots, is frequent, and traceable to the involved area. 

Malignant disease of the vertebrae, which occurs at times as the result of 
metastasis following the removal of pelvic or abdominal neoplasms, is char- 
acterized by intense local and referred pain, which is exceedingly difficult 






BACKACHE 543 

to control. Spondylitis deformans (hypertrophic arthritis) occurs most fre- 
quently in men after the age of thirty-five ; the general and spinal rigidity, 
rounded kyphosis, and characteristic referred pain due to root pressure 
should make the diagnosis clear. Finally, the Rontgen ray will demonstrate 
the presence of definite lesions. 

Static backache may so closely simulate a sacroiliac sprain as to be 
almost indistinguishable ; in fact, with static backache there is always strain 
or tension on the sacroiliac joints. At times this is the most noticeable 
result of faulty posture. In sacroiliac sprain due to falls or blows or the 
result of traumatism incident to labor, the history of the case will reveal the 
origin of the trouble. 

Treatment.— It is obvious that in many cases gynecologic and ortho- 
pedic treatment must be combined. Displaced pelvic viscera must be re- 
stored to good position and these must be maintained by operation or by 
mechanical support {e.g., a pessary). Displaced abdominal viscera must be 
returned to their normal position, and a relaxed abdominal wall must be 
supported. The measures adopted for the latter purpose {e.g., a properly 
constructed corset) form a part of the treatment of static backache, as will 
be seen later. 

Orthopedic Treatment. — Since static backache is due to a disturbance of 
balance in the direction of forward or backward shifting of the center of 
gravity, and consequent strain and fatigue of joints and muscle groups, to be 
successful any method of treatment must restore the equilibrium and relieve 
joint and muscle strain. In restoring balance one must remember that he is 
dealing with the entire weight-bearing column, and not with one particular 
part of it. 

Two important factors that require consideration at the beginning of the 
treatment are the shoes and the corsets — shoes, to give the individual an 
efficient base of support, and corsets, to secure the proper relation between 
the trunk and the lower extremities. 

Shoes may be so constructed as to correct flattening of the arch and pro- 
nation of the foot. Flattening of the arches should be treated by having 
foot-plates built into the shoe or by wearing leather and felt inlays under 
the arch. Pronation that is not corrected by wearing the proper arch sup- 
port may be dealt with by raising the inner edge of the shoe from three- 
sixteenths to one-quarter of an inch. The heel of a shoe has an important 
bearing upon the distribution of the weight superimposed upon the foot. 
The higher the heel, the greater the weight that must be borne by the ball 
and arch of the foot. For this reason, and because their use leads to de- 
formity of the toes and heads of the metatarsal bones, excessively high heels 
must be regarded as injurious. The height of the heel also has an impor- 
tant bearing upon the equilibrium of the body above, and the relationship 
between the lower extremities and the trunk in the position of the line of 
the center of gravity. By raising the heels of the feet (in cases of forward 
displacement of the center of gravity), high-heeled shoes tend to effect a 
spontaneous and unconscious correction of attitude and a displacement 
backward of the center of gravity. For this reason they may be prescribed 
successfully in cases of static backache of the " kangaroo " variety of de- 



544 GYNECOLOGY 

formity. In backache due to deformities of the " gorilla " type, the heels 
may be lowered in order to favor a forward displacement of the center of 
gravity. Whatever form of shoe is selected, the physician should impress 
upon his patient the desirability of wearing shoes of the same size, form, and 
heel throughout the entire day. 

Corsets are used in the treatment of static backache for the purpose of 

Fig. 448. Fig. 449. 




Fig. 448. — Corset for kangaroo posture. (After Dickinson and Truslow.) 
Fig. 449. — Corset for gorilla posture. (After Dickinson and Truslow.) 

correcting postural abnormalities of the " kangaroo " or " gorilla " type 
(Figs. 448 and 449). These corsets should be so fashioned as to throw the 
trunk backward (usual) or forward (rare) upon the pelvis. In order to 
do this the corset must grip the pelvis firmly, thus fixing it and adding 
strength to the sacroiliac articulation. It must also support the lower ab- 
domen, and in this way correct the visceroptosis that is present. The 
proper corset, therefore, fits the patient snugly about the pelvis, so that it is 
capable of binding the bones together and of forming a fixed base, from 



BACKACHE 



545 



which its shape will influence the relation of the trunk to the pelvis. The 
front is straight and begins over, or immediately above, the pubic crest; it is 
not high in front ; its back is so curved in at the wast-line as to correspond 
to the normal dorsolumbosacral curve, and it is slightly incurved at the 
sides. The good corset firmly encircles the pelvis, supports the lower ab- 
domen, elevates the chest and shoulders, throws the center of gravity back- 
ward, and reinforces the muscles of the back. The corset required for the 
unusual " gorilla " type must be longer behind, so as to throw the shoulders 
slightly forward, and its incurve behind must be flattened in the dorsal 
region. A properly devised corset (Figs. 450 and 451) does not constrict the 
waist, and the pressure it exerts is greatest at its lowest point and becomes 
progressively less as its upper borders are approached. 



Fig. 4SO. 



Fig. 451. 





Fig. 450. — Bad type of corset. (After Dickinson and Truslow.) 
Hour-glass shape, maximum pressure at waist line, chin and shoulders 

thrown forward, inlet leveled. 
Fig. 451. — Good type of corset. (After Dickinson and Truslow.) 

When the backache is very severe and marked lordosis is present, the 
corset may be supplemented advantageously by a support of the Jones type. 
This consists of a triangular leather back-piece, reinforced with two light 
steel uprights and an abdominal pad attached to the back-piece by straps. 
The back-piece should extend from the end of the sacrum to a point just 
below the shoulder-blades. It is worn under the corset, and when prop- 
erly applied and adjusted, aids materially in splinting the back and lifting 
the abdomen. Merrill has designed an excellent splint (see Fig. 453). 

A properly fitted corset or corset and brace may be almost unendurable 
at first ; it often so radically changes the carriage and figure of the woman as 
to cause mental as well as physical distress. The clothing needs alteration, 
since the waist-line is larger, etc. ; but if she is encouraged to persist in wear- 
ing the new corset, and proper carriage and dress are insisted upon, after a 
little time the corset that at first appeared unendurable becomes almost in- 
35 



546 GYNECOLOGY 

dispensable to her comfort, and the improvement in figure becomes a source 
of gratification. For women engaged in hard work the snugly fitting corset 
is especially trying at- first. 

After fitting the patient with the proper shoes and corsets, she should be 
directed to rest for the greater part of each day until muscle irritability, 
spasm, and tenderness have subsided. Suitable exercises should now be 
prescribed, which will improve the poise and strengthen the muscles gen- 
erally, but especially those of the back and abdomen. In poorly developed 
and weak subjects massage may be a valuable preliminary. The aim of the 
treatment should be to so strengthen the muscles and correct the carriage 
that proper equilibrium may be maintained without artificial support. Never- 
theless, in spite of the most painstaking efforts, the patient may always 
require the assistance of specially constructed corsets and shoes. In emaci- 
ated subjects it is highly important to increase the weight, and every effort 
toward effecting that end should be employed. Probably the most difficult 
cases occur in the very fat, and here strict regulation of the diet is imperative. 5 

SACROILIAC SPRAIN 

Etiology. — The sacroiliac articulation is exposed to considerable strain. 
Being the joint connecting the spine and the pelvis, it must bear the weight 
of the superimposed spinal column, thorax, upper extremities, and head when 

5 The treatment outlined by Dickinson and Truslow is as follows : 

The Mechanical Treatment of the " Kangaroo " Type 

A. Supportive. 

i. The corset (Fig. 448) must have: (a) Low abdominal support; (b) front lines 
straight, slanting slightly forward as carried upward and with inside pressure de- 
creasing as ascending; (c) about the pelvis, tight circumferential lines, requiring 
reinforcement with inelastic webbing; if there is sacroiliac strain (d) the back 
ascending lines should be made more nearly perpendicular than is the patient's 
back. Sometimes light steel reinforcement is necessary. 

2. Support of the feet: (a) The patient may at first wear higher heels than in the 
other type of posture, but the corset correction of the poise of the trunk tends auto- 
matically to adjustment of the knee and foot balances; (b) special foot-braces may 
be used, if otherwise indicated, but the plantar arch unbalances are not usually 
due to the malpositions of faulty anteroposterior posture. 

B. Gymnastic. 

1. Educative : train posture. 

2. Muscle building : especially abdominal, buttocks, and calf muscles. 

The Mechanical Treatment of the " Gorilla " Type 

A. Supportive. 

1. The corset (Fig. 449) must have: (a) Back lines curved in and forward for the 

hollow of the back. A special sacral pad, thicker and broader above than below, may 
be inserted at the proper place inside the corset to help in shifting the lower spine 
forward, (b) About the pelvis, tight circumferential reinforcement, especially if 
there is sacroiliac strain; (c) low abdominal support; (d) the front ascending lines 
should be straighter than the present pendulous abdomen deformity, and carried 
as much forward as ascending. 

2. Support of the feet: (a) Height of the heels should be reduced as rapidly as pos- 
sible. Here the corset correction tends automatically to correct the faulty knee and 1 
foot balance, but the_ general correction of the position must not be retarded by j 
high heels; (/;) special foot-braces or specially constructed shoes are often indi- 
cated to raise the depressed and painful metatarsal arches. 

B. Gymnastic. 

t. Educative: train posture.^ 

2. Muscle building : especially scapulovertebral, abdominal, anterior thigh (knee ex- 
tensors), calf, and toe flexor muscles. 



BACKACHE 547 

the individual is standing or sitting. The sacroiliac joints are also exposed 
to strains upon the bony ring and arches of the pelvis, from within or from 
without, e.g., the passage of the fcetal head during labor falls upon the but- 
tocks, jars while riding astride, etc. Every movement of flexion or extension 
of the trunk throws some strain on this joint, which depends for its integrity 
upon the interlocking of the opposed bony surfaces and the strength of the 
ligaments binding them together. The strongest ligaments of the joint are 
those that run between the posterior surfaces of the iliac bones and the pos- 
terior surface of the sacrum. The anterior ligaments are much thinner and 
weaker, but they are reinforced by the iliopsoas and pyriformis muscles. 
The sacroiliac joint is protected from lateral strain by the bony girdle which 
is formed by the junction of the innominate bones in the symphysis pubis. 
The firmness of the articulation at the symphysis is sometimes imp-aired 
during pregnancy, and the continuity of the anterior bony ring may be 
broken by faulty union following symphysiotomy and pubiotomy. When- 
ever this anterior bony ring is broken, the anterior surface of the sacro- 
iliac articulations is exposed to lateral strain. Difficult labors result in 
sacroiliac strains, produced either by the pressure exerted by the fcetal head 
as it is molded or dragged through the pelvis with forceps, or by positions 
such as the Walcher, which are designed to increase the diameter of the 
pelvic inlet by employing all the mobility in the pelvic joints. 

Acute trauma is a prolific cause of sacroiliac sprain. It may also be due 
to violent falls upon the buttocks; twisting falls, the result of slipping; the 
sudden placing of a heavy strain upon one leg, or of violent muscular effort 
on one side to regain the equilibrium. 

A fact not widely recognized is that the sacroiliac joint may be exposed 
to undue strain in the course of abdominal operations if no provision is made 
for the support of the lumbar spine and the lumbosacral curve, or for the 
knees when the legs are straight. There is often considerable downward 
pressure on the pelvis by the operator or his assistants, and in the uncon- 
scious patient the strain of the sacroiliac articulation so imposed cannot be 
overcome by muscular action or support. Many persistent backaches fol- 
lowing operation may be laid to this source. General diseases or conditions 
of wasting and ill-health may impair the muscular and ligamentous strength 
of the articulations in general, and since the sacroiliac joint is the one that 
bears the greatest strain, it may be affected first. Sacroiliac weakness is 
often present in patients exhibiting postural defects, obesity, muscle 
atrophy, general relaxation of the muscular tissues, or visceroptosis. 

Symptoms. — When the sacroiliac joints are taxed beyond their strength, 
the ligaments are overstretched, an osteo-arthritis of mild or severe grade 
may be set up. and every tax or strain upon the joint may become painful. 
The pain may be localized directly over the articulation posteriorly, on one 
or on both sides, corresponding to the lesion, or, by virtue of the intimate 
association of the lower part of the joint anteriorly with the lumbosacral 
cord, it may extend down the backs of the thighs (sciatica). 

The pain in sacroiliac sprain is increased by any position or exertion 
that puts tension on the ligaments or that necessitates motion, however 
slight, of the joint. Bending the spine forward, backward, or to one side, 



548 GYNECOLOGY 

assuming the recumbent or the erect posture after lying flat on the back, 
rising from a chair, etc., are among the common movements that cause pain. 
The patient is usually most comfortable lying on the back with the thighs 
flexed and the lumbar curve supported by a pillow. In getting out of bed or 
rising from a chair the patient may turn to one side and use the arms to 
push the body up into the desired posture. Occasionally the prone position 
is uncomfortable and only a lateral posture may give relief. 

Examination and Diagnosis. — In marked cases of sacroiliac sprains the 
diagnosis is easy, but in mild cases it may be difficult. The following tests may 
be made : With the patient lying supine, the leg and thigh, with the knee extended, 
of each side in turn is grasped by the hand and carried as far as possible 
over the abdominal surface (hyperflexion). Then, with the patient lying 
prone, the thighs are hyperextended. The patient is now placed on her left 
side ; the sacrum and lower spine are grasped with the left hand of the ex- 
aminer and fixed, while with the right hand the thigh is hyperextended. 
The same maneuvers are carried out on the opposite side. Massive per- 
cussion of the hip is performed at this 
time, using the fist of the right hand as 
the plexor, and the outstretched left hand, 
placed over the upper ilium and the ilio- 
femoral articulation, as the pleximeter. 
The patient now stands erect, with the 
knees fixed. She is directed to bend for- 
ward, backward, to the right, and to the 
left as far as possible, and to twist the 
body first to one side and then to the 
other. Direct pressure or percussion may 
now be made over the articulation itself. 
, These movements are all designed to bring 

Fig. 452.— Storm's sacro-ihac belt. . , « «. . , ° 

some tension to bear on the ligaments of the 
sacroiliac articulation, or to produce motion in the joint. In case of a sore or 
sprained articulation, one or more of these movements will cause pain, the seat of 
greatest intensity corresponding to the affected articulation. Nevertheless, mod- 
erate degrees of sacroiliac sprain may be encountered in which, even after these 
tests have been made, the examiner may be uncertain as to how important a factor 
relaxation of this joint may be in the production of a given set of symp- 
toms. Under such circumstances the therapeutic test will serve to differ- 
entiate pain due to sacroiliac sprain from that due to other causes. The 
treatment for the relief of sacroiliac pain should be applied and the 
effect observed. 

Treatment. — The treatment of sacroiliac sprain consists in fixation of 
the joint. The degree to which this is desirable depends upon the severity 
of the lesion. For the severest cases, a plaster cast will be required. For 
those that fall into the hands of the gynecologist, fixation by means of a 
sacral pad and adhesive plaster straps, corsets, or braces will be sufficient. 
In suspected cases a pad may be placed over the sacrum, and a leather belt 
may be strapped tightly about the pelvis, care being taken to see that it 
envelops the bony pelvis and passes below the iliac crests; adhesive plaster 




BACKACHE 



549 






Fig. 453. — Merrill's sacroiliac splint. 

B. Same as .4 , with the exception of the postero-lateral steel uprights, attached 
to corset, with straps for adjustment. C. Same as A, with posterior uprights and 
shoulder straps. D and D l . Caliper splint. Same as A, with posterior uprights 
rigid and two lateral uprights movable, the latter adjusted by posterior straps. 
Upper ends lateral uprights pass in front of shoulders to force shoulder girdle 
backward, to give support to spine in direction of sagittal plane. Lateral bars 
adjustable by posterior strap. 



550 GYNECOLOGY 

may be applied with a similar object in view. Relief of pain may be 
almost immediate. 

Should the therapeutic test be positive, the patient may be provided 
with a more permanent means of support in the form of a brace or a corset 
(Figs. 452 and 453), or a combination of the two. Sacroiliac sprains are 
often present in conjunction with static backache, relaxation of the abdom- 
inal parietes, and visceroptosis, so that treatment for the relief of the pain- 
ful articulation must be combined with that of the other condition present: 
Thus a brace may be combined with a corset that corrects a habitual faulty 
posture of the patient or that supports the lower abdomen and ptotic viscera. 

Prognosis. — As a rule, the prognosis of sacroiliac sprains is good. The ulti- 
mate result depends upon the degree of the injury, the thoroughness of the treat- 
ment, and the general health of the patient. In severe cases complete fixation by 
means of a plaster cast does much to insure a satisfactory outcome. 

TOXIC ARTHRITIS 

An actual inflammation of the articular cartilages and ligaments of 
the vertebral, lumbosacral, or sacroiliac joints may be the source of per- 
sistent backache. It is caused by a deportation of bacteria from distant 
foci of infection, particularly from the teeth, tonsils, and nasal sinuses. 
Toxic arthritis is usually engrafted upon chronically congested and strained 
joint surfaces. This condition must always be suspected in rebellious cases 
of static backache or sacroiliac sprain. The symptoms persist in spite of 
correction of posture and the wearing of suitable corsets, braces, and shoes. 
As a rule, the lower spine and sacroiliac joints are particularly tender and 
the symptoms out of proportion to the degree of postural defect. There may 
be no history of acute trauma, such as follows a fall or labor. The condition 
may arise without any previous indication of static or sacroiliac disability. 

The treatment of toxic arthritis is the treatment of static backache or of 
sacroiliac sprain, plus the localization and eradication of foci of infection in 
the teeth, tonsils, nasal sinuses, and gall-bladder. 

PENDULOUS FAT ABDOMEN J RELAXED ABDOMINAL WALL 

An excessively fat and pendulous abdomen is a frequent source of distress to 
women past middle age (Fig. 454). It may be the result of insufficient exercise 
combined with errors in diet; it may be an evidence of a diminution of the 
ovarian secretion as observed in the premature, artificial, or natural meno- 
pause. The exact cause is often undeterminable. Apart from the aesthetic 
reasons for which the patient may seek relief, the overhanging fat is a 
source of annoyance and results in maceration and low-grade inflammation 
of the skin beneath it. 

In a large proportion of cases the pendulous accumulation of fat is asso- 
ciated with and undoubtedly aggravates the symptoms of insufficiency of 
the abdominal wall, separation of the rectus muscles, and ventral hernia. 
Under such circumstances, the condition ceases to be a mere cosmetic 
defect, and requires attention because of the part it plays in the production 
of symptoms. If the latter are treated surgically and no attention is paid to 



BACKACHE 



551 



the fat, the result may be unsatisfactory, because of the fact that a con- 
tributing factor to the discomfort of which the patient complained has been 
left undisturbed. 

The intelligent and well-to-do woman will overcome an unwelcome addi- 
tion to her girth by the use of a suitable corset or an abdominal binder. A 
properly fitted straight-front corset will elevate and support the pendulous 
folds. If the accumulation of fat is associated with relaxation of the ab- 
dominal wall, such a corset or binder will also relieve the symptoms of abdominal 
insufficiency. It is absolutely necessary, however, that careful attention be given 




Fig. 454. — Fat overhanging abdomen; -f marks anterior superior spine. 



the application of the corset, and that it be renewed from time to time. A 
corset of this sort is above the average in cost, since it must often be con- 
structed especially for the patient. The carrying out of these measures for 
the correction of the defect by the use of a corset means the expenditure of 
time, money, and care. 

Surgical treatment, on the other hand, offers a speedy relief. If the 
pendulous fat is not associated with relaxation of the abdominal wall, 
hernia, or an intra-abdominal disease that requires operation, resection be- 
comes a very simple matter, requiring but brief anaesthesia, and an opera- 
tion that is practically free from danger. When the fat is associated with 



552 GYNECOLOGY 

other lesions requiring operation, its resection involves no added risk and 
consumes but a few extra minutes. 

The lines of excision should be transverse. The flaps of fat should be 
brought together with interrupted sutures, and the wound should be drained 
at each angle for twenty-four hours. 

COCCYGODYNIA 

Coccygodynia is the term applied to painful sensations originating in 
the region of the coccyx, and produced by lesions of its constituent bony 
segments and the joints between them or the sacrococcygeal articulation. 
The exciting cause is an injury to the coccyx affecting the continuity of its 
bony segments or its joints. Solution of continuity takes place most com- 
monly in labor, the foetal head, in its passage through the pelvic outlet, over- 
extending the sacrococcygeal articulation with resulting fracture of its bones 
or rupture of its joints. Other causes may be operative, such as kicks or 
falls, the trauma being received directly upon the bone, with resulting 
osteitis and pericoccygeal cellulitis. 

Symptoms. — The symptoms consist of pain in the affecte-d area when 
sitting, or especially in rising after being seated, the pain being brought 
about by muscular action that pulls upon or moves the coccyx. The pain 
may be excited, also, by defecation. The patient commonly sits more upon 
one buttock than upon the other, so that the weight rests on one ischial 
tuberosity and does not reach the coccyx. In rising from the sitting posture 
the patient assists herself by using the hands and arms, pushing herself up 
from the seat or along the back of the chair. The pain may be of a more 
jiidefinite type also, occurring now and then, and apparently not depending 
upon any particular or special muscular effort. 

Diagnosis. — The diagnosis can usually be established by making a com- 
bined examination of the coccyx with a finger in the rectum and the thumb 
over the coccygeal raphe. Abnormal mobility with exacerbation of the pain, 
marked deformity of the coccyx, with ankylosis, and thickening of the 
articulation may be found. If no striking abnormality is discovered, and 
the symptoms complained of do not manifest themselves as the result of the 
examination, one must be wary of ascribing the symptoms to the coccyx, or 
of expecting a cure to follow its removal. 

Treatment. — The treatment consists in removing the coccyx, although 
palliative measures, such as counter-irritation and the exhibition of sali- 
cylates, may afford temporary relief. A median incision is made directly 
over the coccyx through the raphe, from the tip to the point of its articulation 
with the sacrum. The surface of the bone is freed up past the sacral joint. 
With heavy, blunt-pointed scissors it is then cut loose from its attachments 
all around. After the bone is entirely freed, it should be grasped with a 
sequestrum forceps, bent forward at the coccygeosacral junction, and the 
ligaments of the joint divided with a heavy knife; bleeding vessels should 
be ligated and the wound closed with interrupted sutures of silkworm gut. 
A strip of rubber dam may be left in the lower angle of the wound for 
twenty-four hours to insure sufficient drainage. 






BACKACHE 553 

BIBLIOGRAPHY 

Dickinson, R. L. : "Toleration of the Corset, Prescribing Where One Cannot Proscribe.' 3 

Am. Jour. Obst.. 191 i. lxiii. Xo. 6. 
Dickinson. R. L.. and Truslow, W. : "'Averages in Attitude and Trunk Development in 

Women and Their Relation to Pain."' Jour. Am. Med. Asso., 1912, lix, 2128. 
Goldthwaite, J. E. : " The Relation of Posture to Human Efficiency and the Influence of 

Poise Upon the Support and Function of the Viscera." Bost. Med. and Surg. Jour.. 

1909, clxi. 839. 
Litzenberg. J. C : " Sacroiliac Joints in Obstetrics and Gynecology." Trans. Sect. O., G. 

and A. S.. A. M. A.. 1917. 93. 
Lovett, R. W. : " The Causes and Treatment of Chronic Backache." Jour. Am. Med. Asso., 

1914, lxii, 1615. 
Meisenbach. R. O. : " Sacroiliac Relaxation, with Analysis of Eighty-four Cases.'" Surg., 

Gynec. and Obst. 191 1. xii. 411. 
Reynolds, E., and Lovett, R. W. : " An Experimental Study of Certain Phases of Chronic 

Backache." Jour. Am. Med. Asso.. 1910. lvi, 1033. 
Smith, R. R. : " Enteroptosis with Special Reference to Its Etiology and Development/' 

Jour. Am. Med. Asso., 1910, lvii. i860; Ibid.: "A Study of Children with Reference to 

Enteroptosis."' Jour. Am. Med. Asso., 1912, lviii. 385. 
Wetherill, H. G. : " Subinfection from Foci in the Pelvis and Abdomen." Trans. Sect. O., 

G. and A. S.. A. M. A.. 1915. 172. 



CHAPTER XXIX 
GONORRHOEA 

General Peculiarities. — The initial s) T mptoms of gonorrhoea are prone to 
be less acute in the female than in the male, and the disease is, therefore, 
more insidious in the former. It is also capable of producing more harm 
and its ravages frequently lead to chronic invalidism or even to death. The 
frequency of gonorrhoea in the female is difficult to estimate, since it varies 
greatly in the different classes of society. Johnson reports that in 1901 the 
Section on Hygiene and Sanitary Science of the American Medical Asso- 
ciation sent the following question to many of the leading gynecologists in 
this country and in Europe : " What is the proportion of cases of pelvic 
inflammation coming under your care which are attributable to gonorrhoeal 
infection ? " The general average of the proportions given was 40 per cent. 
Noeggerath first drew attention to the frequency and the seriousness of the 
disease in women. He believed that eight out of every ten married men in 
New York city had been infected with gonorrhoea before their marriage, 
and that a majority of them subsequently infected their wives. While this 
is undoubtedly an exaggeration, it is nevertheless probably true that no 
single disease of the genital organs causes half so much suffering, mutila- 
tion, and direct mortality as gonorrhoea. Bumm estimates that one-third of 
the cases of sterility in women is due to the gonococcus. The number of 
instances of race suicide due to this disease, if it could be ascertained, 
asserted Johnson, would equal the number of lives lost from pneumonia, 
tuberculosis, or typhoid fever, or perhaps from all these combined. 

The gonococcus is a peculiar organism. While it is extremely hard to 
grow upon culture media, and is incapable of producing gonorrhoea in ani- 
mals, it is nevertheless one of the most difficult organisms to eradicate from 
the generative organs of women once they have been infected. As com- 
pared with the streptococcus, the gonococcus has little power of penetration. 
Its influence upon the cutaneous surface or the modified skin covering of 
the vagina or the vulva is but slight. Within glandular structures, however, 
it produces a serious, persistent inflammation that manifests but little ten- 
dency to undergo spontaneous cure. Wertheim has shown that the gono- 
coccus does not affect the mucous membranes solely, but occasionally in- 
vades and becomes embedded in other tissues, where it grows and produces 
a reaction. Thus the organism may rarely be the cause of parametritis. It 
has also been found in the wall of the Fallopian tube, at a considerable dis- 
tance from the mucosa. Gonorrhoeal arthritis and gonorrhoeal endocarditis 
are further evidences of the truth of Wertheim's assertion. A peculiarity of 
the transmission of gonorrhoea is that infection from an old gleety discharge 
(morning drop), when no acute symptoms have occurred and the incumbent 
is perhaps unaware of the true condition, may produce a gonorrhoea of the 
most virulent form in a second person. Again, married persons infected 
554 



GONORRHCEA 555 

with the gonococcus may become more or less immune to their own par- 
ticular organism, so that the symptoms and signs of the disease may sub- 
side completely. If these persons live apart from each other for a consid- 
erable period of time, upon resuming sexual intercourse a violent gonorrhoea 
may be set up in either individual, although both have been virtuous during 
their separation. Or if the infection is transferred from a married couple to 
a third person and then again to one of the original incumbents, it is capa- 
ble of producing a violent attack. 

Latent and Residual Gonorrhoea. — Chronic gonorrhoea may exist in an 
individual without producing noticeable symptoms. Under such conditions 
the host may be entirely unaware of its existence until, following some 
unusual irritation of the sexual organs, it reappears in an acute or in a sub- 
acute form. This fact was first noted by Noeggerath, who spoke of it as 
* l the latency of gonorrhoea." Luther believes that a more nearly correct 
phrase would be " the latency of the gonococcus." Fritsch speaks of gonor- 
rhoea without symptoms. Residual gonorrhoea is a chronic affection, which, 
as Saenger asserts, depends less upon the presence and the activity of the 
gonococcus than upon the tissue changes produced by the organism during 
a previous infection. 

Symptoms. — Gonorrhoea in the female does not pursue so virulent an 
initiative course as it does in the male. Indeed, in an uncleanly woman or 
in one of sluggish habits the disease may exist for some time before the 
patient is aware of it. This is due to the fact that the urethra in the female, 
being short and not surrounded by erectile tissue, as in the male, an inflam- 
mation of the mucous membrane is not so painful and difficulty in urination 
is not so marked. Furthermore, in the female, gonorrhoea is not necessarily 
first localized in the urethra, but may occur primarily in the cervix or in the 
vulvovaginal glands — in either situation it is less likely to produce acute 
initial symptoms than when it occurs in the urethra. Occasionally, either 
because the infection is highly virulent or the affected parts are unusually 
susceptible, gonorrhoea does produce severe initial symptoms. In such 
cases, in addition to a violent local reaction in the affected parts (see 
urethritis, page 440; vulvitis, page 167; endocervicitis, page 223), slight con- 
stitutional disturbances may be present. 

The urethra is the seat of an initial attack of gonorrhoea more often 
than are the glands of Bartholin or the cervix. For this reason the symptoms 
at the onset of a gonococcus infection in women are often vesical. The 
patient complains of frequent and painful urination, a burning pain about 
the external urinary meatus, and a leucorrhceal discharge. It is a grave 
mistake at this time to make a vaginal examination or to introduce a 
speculum unless there is a leucorrhceal discharge from the vagina. If the 
vulva is carefully cleansed with pledgets of cotton, and the lips of the 
smaller labia are separated so that the vaginal introitus is exposed to view, 
the presence of a vaginal discharge can at once be detected. In cases of 
doubt it is better to permit a cervical nidus of infection to go untreated for 
a short time than to run the risk of infecting a healthy cervix by making an 
examination or carrying out a treatment inside the vaginal orifice. In the 
subacute or in the chronic stage of gonorrhoea the infection is frequently 



556 GYNECOLOGY 

localized in the glands of Skene, the glands of Bartholin, and the cervix. 
At this time there very often appear, at the urinary meatus (Skene's 
tubules) and about the orifices of the ducts of the vulvovaginal (Bartholin's) 
glands, small areas that resemble flea-bites in appearance. These are known 
as the macula? gonorrhccica, or gonorrhoeal macules. They may be found 
also in the posterior vaginal fornix when the cervix is the seat of gonorrhoea 
and the posterior vaginal fornix is constantly bathed with gonorrhoeal pus. 
In old cases of gonorrhoea .ill gross evidences of the disease may disappear 
from the external genitalia and the cervix, although the disease may still 
be present and be capable of infecting another person. The discharge from 
the glands of Skene, from Bartholin's glands, and from the cervix, though 
it appears as only a small amount of turbid mucus, will sometimes show 
the gonococcus. Under such circumstances it may be necessary, in making 
a search for the gonococcus, to examine smears taken at different times 
between the menstrual periods ; occasionally the organism will be found in 
the cervical discharge only preceding or following a menstrual period. 

From what has been said it will readily be seen that in the chronic latent 
forms of gonorrhoea a woman can, by careful douching, etc., remove all 
gross evidences of the disease. Physicians should make it an unvarying 
practice to instruct patients not to use a douche before coming for examina- 
tion. Unless such instructions are given, most women, from motives of 
cleanliness, will take a douche immediately before consulting a physician. 
The other structures affected by gonorrhoea are the vagina, the endo- 
metrium, the Fallopian tubes, and the pelvic peritoneum. The disease is 
considered under the sections that deal with these structures. 

Diagnosis. — Brose and Schiller believe that the recognition of the gono- 
coccus in smears is not necessary for confirming the diagnosis of gonorrhoea. 
The coincident infection of the urethra, Bartholin's glands, and the cervix, 
and especially the presence of gonorrhoeal macules at one of these situations, 
are sufficiently significant to' warrant a diagnosis. Neisser and his pupils 
insist upon the recognition of the gonococcus, and this is important if it is 
desired to establish the diagnosis for forensic purposes. 

The Technic of the Preparation and the Examination of Smears for the 
Gonococcus. — In the preparation of smears for the detection of the gono- 
coccus it is important to avoid the transference of infectious matter from one 
point to another. For this reason the platinum wire, or the applicator, or 
whatever instrument is used to transfer the suspected discharge to a glass 
slide, should be carefully wiped clean and sterilized in an alcohol flame after 
each smear is made. The glass slides should be well cleaned before using, 
and each one should be labelled immediately after it is prepared. The 
smears must be made very thin. Glass slides are preferable to cover- 
glasses. If the smears are contaminated with a lubricant of any kind — 
vaseline, glycerine, etc. — they will not stain well ; hence, in making the 
smears care should be taken that the physician's hands be free from these 
substances. It is unnecessary to obtain smears from the vulva or the 
vagina, except in cases of actual vulvitis or vaginitis in young children. 
Under such circumstances it would be difficult to procure the discharge, as 



GONORRHCEA 



557 



is done in the adult, from the cervix, the urethra, and the vulvovaginal 
glands, and for that reason the platinum loop may be scraped along the 
vulvar surface or passed directly into the vagina (Fig. 455). 

At least three hours after the passage of urine and twenty-four hours follow- 
ing the use of a vulvar or vaginal douche the patient should be placed in the dor- 
sal position upon an examining table, and the external genitalia exposed to view. 
The entire vulva should be gently wiped free from discharge. The forefinger 
of the left hand should be introduced into the vagina and the palmar sur- 
face turned upward. The contents of the urethra are now expressed by 
drawing the finger forward and pressing it steadily against the floor of the 
urethra. The end of a platinum wire or an applicator is used to transfer a 
portion of the mucopus to a glass slide. In chronic cases it may be neces- 
sary to strip the urethra several times in order to secure a sufficient quan- 
tity of discharge. In such cases, too, the excretion from Skene's tubules is 
more prone to contain the gonococcus than is the secretion from the 
urethra itself. The orifices of Skene's tubules are about 2 mm. within the 
urinary meatus, on the floor of the urethra. In the parous woman, in 
whom there is some eversion of the meatus, these orifices can readily be 



Fig. 455. — Smear of pus from urethra (u), vagina (v), and cervix (c). 



seen ; in nulliparae the lips of the meatus must be slightly everted in order 
to expose the orifices. To collect the discharge from the ducts themselves 
the end of a straight platinum wire should be passed directly into them, or 
they may be stripped, in the manner previously described for the urethra. 

Practically it makes no essential difference whether the gonococcus is 
found in the urethra or in Skene's tubules, and the discharge from the tubules 
may be collected together with that from the urethra. In chronic cases, 
however, the urethra may be entirely free, whereas the tubules will be the 
seat of a chronic infection. Even a small amount of thin, yellowish-white 
discharge may contain large numbers of gonococci. 

The secretion of the vulvovaginal glands should next be secured by 
gently compressing the glands, first on one side and then on the other, 
between the thumb and forefinger. In doing this the forefinger is introduced 
just w r ithin the vaginal orifice. A smear may also be taken by passing a 
straight platinum wire directly into the duct of the gland. 

Smears from the cervix are taken by exposing the part with a bivalve 
speculum. The portio vaginalis and vaginal cervix are thoroughly 
cleansed of discharge, and the platinum wire or applicator is introduced 



558 GYNECOLOGY 

into the cervical canal, care being taken not to pass the limits of the 
internal os. The loop of the platinum wire or the applicator should 
be made to engage the folds of the cervical mucosa at the circumference of 
the cervical canal. In this way one is more apt to find lurking gonococcL 
The slides should be fixed and stained as described on page 128. For the 
detection of the gonococcus an oil-immersion lens will be required. As a 
rule, if the discharge is purulent and the smears show myriads of bacteria, 
the gonococcus will not be found. A number of cocci that slightly re- 
semble the gonococcus may confuse the beginner and give rise to error. 
When the gonococcus is present, it can usually be recognized from its form 
or from its position within the epithelial or the pus-cells. If the investigator 
is unaccustomed to bacteriologic work, it is well for him to have at hand a 
type specimen of the gonococcus, and to compare it with the specimen 
for diagnosis. 

Prognosis. — If the disease is carefully treated during the initial stages, 

and if reinfection can be prevented, the prog- 
nosis is favorable. In old cases, where the dis- 
ease has persisted either as the result of insuffi- 
cient or of careless treatment or because of 
repeated infection, the prognosis is doubtful. 
Much depends, of course, upon the organs in- 
volved. Once the disease has passed into the 
uterine cavity or into the Fallopian tubes, cure 
becomes difficult. Gonorrhceal salpingitis or 
pyosalpinx usually demands operation. Even 
after both tubes have been removed in cases of 
bilateral pyosalpinx a gonococcal infection may 
Fig. 456.— Appearance of gonococci persist in the endometrium, cervix, vagina, and 

m stained preparation. r _ » • o ' 

vulvovaginal and Skene's glands. This is, how- 
ever, rare, most cases recovering entirely after a radical operation if proper 
medical treatment of those foci of infection has been instituted. 

Prophylaxis. — Much has been written upon the subject of prophylaxis. 
Some of the plans suggested for preventing the spread of gonorrhceal in- 
fection have failed signally, whereas others are clearly impracticable. The 
segregation of prostitutes and the examination of them at regular intervals 
has not been entirely satisfactory. This failure is due partly to the fact that a 
woman with chronic gonorrhoea can often, by employing cleansing douches, 
etc., conceal her condition from the physician unless a painstaking examina- 
tion is made and the patient is observed for a length of time and under 
certain conditions that have been discussed elsewhere. The same is equally 
true of the male. It has been suggested that marriage should not be per- 
mitted to take place until a careful examination of the male by a physician 
shows him to be perfectly sound. Such a plan is at present to a great 
extent impracticable. Both sexes should, however, be told of the serious 
nature of the disease and should be made to feel its dangers and the 
responsibility of transmitting it to others. If the truth about gonorrhoea 
were commonly known, few males who were at some time incumbents of 
the disease would marry without seeking professional advice. A knowl- 




GONORRHOEA 559 

edge of the suffering and the dangers incident to gonorrhoea would also go 
far toward discouraging intercourse in the infected and unmarried. For 
the details of the treatment of urethritis, vulvitis, vaginitis, endocer- 
vicitis, endometritis, salpingitis, peritonitis, etc., caused by the gonococcus, 
see the chapters devoted to these subjects. 

BIBLIOGRAPHY 

Bumm : "Die Mikro-organisms gonorrhoischen Schleimhauterkrankungen." Wiesbaden, 
1885 ; Ibid. : " Die gonorrhoischen Erkrankungen der weiblichen Harn und Geschlechts- 
organe." Veit's Handbuch der Gynakologie, Bd. 1. 

Mexge : Handbuch der Geschlechtsk., Vienna, 1910. 

Neisser, A. : " tiber Eine der Gonorrhce eigentiimliche Micrococcusform." Cent, f . d. 
med. Wissens., July 12, 1879, 32 ; Ibid. : " Die Mikrokokken der Gonorrhce." Deutsche 
med. Woch., 1882, xiii, 279 ; Ibid. : " Forensische Gonorrhcef ragen." Aertzl. Sachverst. 
Zeit, 1895, No. 12. 

Koeggerath, E. J. : Die latente Gonorrhce im weiblichen Geschlecht. Bonn, 1872. 

Norris, C. C. : Gonorrhoea in Women. Saunders, Phila., 1913. 

Wassermann, A. : " tiber Gonokokken-Cultur und Gonokokken-Gift." Berlin klin. Woch., 
1897, No. 32, 685 ; Ibid. : " tiber Gonokokken-Cultur und Gonokokken-Gift." Verhand., 
Berl., Arztlicher Med. Gesellschaft, Berlin klin. Wochenschr., 1897, No. 32, 700. ' 

Wertheim, E. : " Zur Frankfurter Gonorrhce-Debatte." Cent, f . Gyn., 1896, No. 48, 1209.. 



CHAPTER XXX 
TUBERCULOSIS OF THE GENERATIVE ORGANS 

Tuberculosis may affect any part of the genital tract, but its most fre- 
quent site is the Fallopian tube. The latter is found to be affected in about 
90 per cent, of all cases of genital tuberculosis. Very frequently the peri- 
toneum is infected coincidentally with involvement of the tube. In 194 cases 
of secondary tuberculosis of the tube the peritoneum was involved in no. 
The next most frequent site of genital tuberculosis is the fundus of the 
uterus ; the cervix is seldom involved. The ovaries are not often invaded. 
Tuberculosis of the vagina is exceedingly rare, and tuberculosis of the vulva 
is the most uncommon variety. 

The incidence in general of tuberculosis of the generative organs in 
woman is about 1 per cent. This proportion has been determined by post- 
mortem examination ; 1 per cent, of all autopsies in females showing tuber- 
culosis of the genital tract. According to Berkeley, in tuberculous women 
there is tubercular disease of the pelvic organs in j.j per cent. According 
to Freriche, Turner, and Stopler, tubal tuberculosis occurs in from 12 to 20 
per cent, of tuberculous women. The proportion of pyosalpinx that is due 
to tuberculous infection is given by various authors as ranging from 3 to 10 
per cent. Grange reported that in 20 per cent, of all cases of tuberculosis of 
the female generative tract coming to autopsy at the St. Georg Hospital 
at Hamburg, the age of the patient was under fifteen ; the greatest number 
occurring the first and the fifth year and the next largest between the tenth 
and the fifteenth year. 

Schlimpert found the greatest incidence (32.9 per cent.) between the ages of 
twenty-one and thirty, and 17.8 per cent, between thirty-one and forty, and 
17.8 per cent, between forty-one and fifty. 

Tuberculosis of the generative organs is usually secondary to a nidus of 
tuberculous infection elsewhere in the body. The genital tract is affected 
secondarily, the disease reaching the tract by the metastatic deposit of 
tubercle bacilli from the blood-stream. This is the most frequent mode of 
infection. The next most common mode of infection is by direct extension 
from a neighboring organ, as, for example, from the peritoneum to the tube. 

In rare instances tuberculosis of the genital organs may be primary, but 
in order to establish the diagnosis positively, a complete autopsy must have 
failed to show a primary focus of infection elsewhere in the body. A pri- 
mary infection may, however, occur as the result of direct inoculation of 
tuberculous material during coitus, examination, and instrumentation. Since 
primary tuberculosis of the vulva, vagina, and even of the cervix, is so 
exceedingly rare, the occurrence of a primary direct infection has been 
doubted. It is probable, however, that the vulva and vagina are more 
resistant to this infection than are the parts higher up. 

The anatomic manifestations, as well as the symptoms and diagnosis of 
560 



TUBERCULOSIS OF THE GENERATIVE ORGANS 561 

genital tuberculosis, vary according to the parts that are involved. The 
disease may, therefore, be considered, as it affects the individual parts, 
bearing in mind that in advanced cases the entire generative tract may 
be involved. 

TUBERCULOSIS OF THE TUBES 

Pathology. — As a rule, both tubes are affected. A preliminary in- 
flammation or catarrh of the mucosa favors the development of tuber- 
culous salpingitis. Faulty development or hypoplasia of the genitalia is a 
predisposing factor. Not infrequently it has its inception during the puer- 
perium. At first the bacilli lodge in the mucosa, in which they produce the 
typical tubercles that sooner or later become necrotic and then caseate. 
Later calcareous infiltration of the caseated areas may take place. These 
changes vary in extent and in degree. Thus in one case the mucosa alone 
may be affected, whereas in another the muscular and serous layer also are 
invaded. The outer part of the tube is usually the portion most extensively 
affected, and shows the greatest increase in diameter. The lesions may. 
however, be most marked toward the isthmus, in which case general dis- 
tention of the tube is not so marked as is the formation of discrete nodules 
or nodular thickenings. 

The abdominal ostium may be open or closed, and the tube may or 
may not be adherent to the surrounding structures. It is usually abnormally 
convoluted, and shows a certain stiffness and hardness. It varies in diameter 
from that of a lead-pencil to that of a finger or thumb : some of the largest 
pyosalpinges ever observed have been tuberculous. The contents usually 
consist of a grayish-yellow, cheesy material, in which areas of calcareous 
deposits may be seen. In large tuberculous pyosalpinges the contents may 
be somewhat fluid and resemble the whitish-yellow suppurative material of 
a tuberculous abscess elsewhere. After removal of the contents the inner 
surface of the tube may exhibit small, grayish-yellow tubercles. The tubal 
wall itself is usually more or less thickened, and if the serous coat is involved. 
the surface is dotted with the small, grayish-yellow tubercles. 

The secondary form of tuberculous salpingitis is believed to run a more 
acute course than the primary form, the abdominal ostium remaining open 
comparatively longer, and adhesions to surrounding structures occurring 
relatively late. There is also more likelihood of the muscular layer becom- 
ing involved. The primary form runs a more chronic course, the abdominal 
ostium closing early, considerable enlargement of the tube taking place, and 
adhesions being widespread. In some of the more chronic cases there is a 
rich overgrowth of fibrous connective tissue and but little tendency to break 
down is manifested. The three forms described by Williams as miliary, 
chronic diffuse, and chronic fibroid are regarded respectively as the begin- 
ning stage of the tuberculous process, the advanced form, and the variety 
in which there is an overgrowth of connective tissue. 

It is important to remember that cases of tuberculosis are encountered 

that are not even remotely suggestive of a tuberculous process. They 

resemble closely the ordinary suppurative conditions, and only by making 

microscopic and bacteriologic examinations can the true nature of the dis- 

36 



562 GYNECOLOGY 

ease be recognized. Other cases are seen in which the diagnosis can be 
made only as a result of a bacteriologic examination, and identification is 
possible only after stained tubercle bacilli have been recognized in the pus. 

Infection of the peritoneum from the tube occurs either through the ab- 
dominal ostium or by direct passage of the infection through the tubal wall. 
Tubal tuberculosis may extend to the endometrium. Only rarely does it 
attack the ovaries, the vagina, and the vulva. In the presence of a mixed 
infection a tuberculous salpingitis may be attended with suppuration. 

Symptoms. — The symptoms of tuberculous salpingitis may in no way 
be distinctive. A salpingitis occurring in a young virgin may be suspected 
of being of tuberculous origin. Salpingitis occurring secondary to a focus 
of tuberculous disease elsewhere in the body, without a history of possible 
gonorrhceal or septic infection, should be examined carefully for evidences 
of a tuberculous nature. 

Probably the most common symptoms are tenderness and pain. A gen- 
eral ill-defined soreness, interrupted by attacks of acute pain, not so severe 
as in the usual form of salpingitis or peritonitis, with elevation of tempera- 
ture, rigidity of the lower abdomen, etc. After the attack passes off — 
which may occur within a week or ten days — the uterus and adnexa are less 
likely to be fixed than after gonorrhceal salpingitis or ordinary pelvic in- 
flammatory attacks of septic origin. The enlargement of the tubes may 
readily be recognized, and in some cases, especially when the isthmus of the 
tube is chiefly involved, with the development of localized thickenings, a 
rosary-like formation can be outlined. Sterility is the rule. No constant 
effect of the disease on the menstrual periods has been noted. Fever of a 
regularly remittent type may be present. Some vesical irritability is often 
observed. The general health may fail, and a leucorrhceal discharge may 
be present. 

When, in addition to the tuberculous salpingitis, the peritoneum is in- 
volved, and there is a tuberculous peritonitis of the disseminated serous 
variety, diarrhoea, pain and tenderness of the iliac fossae, and enlargement of 
the abdomen may supervene. Examination may not disclose anything char- 
acteristic of a tuberculous disease. The nodular condition of the isthmus of 
the tube, believed by some investigators to be characteristic of tuberculosis, 
has been known to exist in gonorrhoeal lesions. The infiltration and exudate 
found in the ordinary gonorrhceal and septic cases are more marked than in 
those of tubercular origin, except in the later stages, when the changes have 
been extremely marked. 

When peritonitis accompanies the tubal disease, ascites may be present. 
The collection of fluid in tuberculous peritonitis is often more or less local- 
ized, and may be so completely localized as to form a tumor that resembles 
an ovarian cyst. The collection of fluid may be situated in the center of the 
abdomen or to one side. Movable dulness is less likely to be present than in 
other forms of ascites. 

Treatment. — The only treatment that can be considered is complete ex- 
tirpation of the tubes. This is done preferably through an abdominal in- 
cision, the ovaries and uterus being spared if possible. 



TUBERCULOSIS OF THE GENERATIVE ORGANS 563 

TUBERCULOSIS OF THE PERITONEUM 

Pathology. — Tuberculosis of the peritoneum is considerably more common 
in the female than in the male. The ratio is about three to one. In females the 
peritoneum is most frequently infected from the tubes. The tubercle bacillus 
also reaches the peritoneal cavity through the intestine, into which they have been 
introduced through the medium of infected milk or meat. The intestine may be 
involved primarily and the peritoneum secondarily, or the bacilli may pass through 
the intestine without causing any lesion and attack the peritoneum primarily. 
Bacilli may be deposited also through the blood current from the mesenteric 
glands or the pleura. Four varieties of tuberculosis of the peritoneum have been 
described by Murphy : (i) The most usual one, the ascitic or serous variety, 
also known as disseminated, miliary, and non-confluent tuberculosis ; (2) 
the adhesive, cystic, or obliterative variety; (3) the nodular, ulcerative, or 
perforative variety ; and (4) the suppurative, circumscribed, or general 
mixed infection. 

As has been stated, the ascitic is the most common variety. The peri- 
toneum presents a congested appearance, with here and there gray fibrous 
plaques and fresh deposits of miliary tubercles, most numerous near the 
ends of the tubes. Cheesy material may be seen escaping from the tube. 
In the adhesive variety the endothelial lining of the peritonal cavity is de- 
stroyed, and connective-tissue products are formed that result in cyst for- 
mation and isolation of certain areas in the peritoneal cavity. There is 
considerable agglutination between adjacent intestinal walls and the peri- 
toneum. In the ulcerative form the tuberculous process has been most de- 
structive, and the involved intestine, mesentery, or pelvic organs are 
destroyed, and are represented by caseous masses surrounded by " dense 
connective-tissue barriers and adhesions" (Murphy). Tuberculous peri- 
tonitis with mixed infection may take the form of any of the three varieties 
just described, plus infection by other organisms. 

Symptoms. — The symptoms of tuberculous peritonitis may come on very 
slowly or appear suddenly. There are tenderness and pain in the pelvis or lower 
abdomen, diarrhoea, and attacks of exaggerated pain combined with nausea 
and vomiting. The general health may be considerably disturbed. The 
menses may or may not be affected. The temperature may be subnormal 
in the morning, and elevated in the afternoon. The abdomen enlarges, and 
the patient becomes pale and emaciated. On abdominal examination the 
findings vary. Ascites may be present, which gives the impression of being 
encysted. The area of fluctuation may take in almost the entire abdomen, 
be limited to the region below the umbilicus, or it may be confined to one or 
the other hypogastric region. " Plaque-like thickenings of the deeper parts 
of the abdominal wall " (Murphy) were pointed out by Edebohls as a sign 
of great value in making an early diagnosis of peritoneal tuberculosis with- 
out ascites. The skin may take on a deep brown, discolored appearance. 
The abdomen may feel " doughy " to the palpating hand. The pain and 
tenderness may undergo periodic exacerbations, with leucocytosis, eleva- 
tion of temperature, increased pulse, nausea, and vomiting. These attacks 
are especially prone to be repeated in the disseminated variety, and are due 



564 GYNECOLOGY 

to an outpouring of tuberculous material from the tubes. The attacks last 
from eight to fourteen days, and bear some resemblance to attacks of appen- 
dicitis, except that the remission is not complete, and an unusual 
sensitiveness continues. 

In the more advanced cases, when the tubes are closed and sealed off, the 
pain is irregular and sharp attacks do not occur. There is more continuous 
pain and tenderness, with recurrent seizures of colic and slight elevation of 
temperature. In the fibrous variety the circumscribed cysts are a more or 
less prominent feature, and when present in the pelvis are frequently mis- 
taken for cysts of the broad ligament. Irregular cystic collection in- 
volving almost any part of the abdominal cavity may also be present. " In 
the mixed infection cases, there may be chills, pronounced elevation of tem- 
perature, diarrhoea, and rapid emaciation" (Murphy). The distinguishing 
features between the tuberculous and the ordinary varieties of general peri- 
tonitis are dependent largely upon the history. 

Treatment. — The treatment of tuberculous peritonitis should be directed 
toward removal of the tuberculous focus, if that is possible, as it is when 
the tuberculous lesion of the peritoneum is secondary to a tuberculous infec- 
tion of the tubes or the appendix. In addition to removing the focus of the 
disease, tuberculous ascites or exudates must be evacuated. Care should be 
taken during the progress of the operation not to add another source of in- 
fection, and a certain amount of reaction in the peritoneum is desirable as 
the result of the laparotomy, in order to produce tissue proliferation which 
may overwhelm and encapsulate the tuberculous peritoneal deposits. When 
the disease is so far advanced that actual destruction of the pelvic viscera 
has occurred and the intestines are very extensively involved, laparotomy 
can do little more than definitely determine the diagnosis. 

TUBERCULOSIS OF THE ENDOMETRIUM 

Pathology. — Tuberculosis of the endometrium is next in frequency 
to tuberculosis of the peritoneum. The lesion is usually secondary to 
a similar process in the tubes. The endometrium about the tubal 
orifices is most frequently invaded. The endometrium is believed to 
be somewhat protected against tuberculosis by the regular monthly ana- 
tomic changes that take place in its structure. Tuberculosis is more fre- 
quent before puberty and after the menopause. The disease may be found 
in the early stage, when it is marked by small, scattered tubercles, or in a 
later stage, when the tubercles have undergone necrosis and caseous degen- 
eration ; when the condition is more advanced, there may be considerable 
involvement of the muscular coat of the uterus, so that the diseased uterus 
may be represented merely by a fibrous bag containing caseous material, or 
the caseous material may undergo secondary infection, with the formation 
of a pyometra. 

In the early stages there may be no enlargement of the uterus, but in 
advanced cases considerable enlargement may take place. The disease ap- 
pears to be more frequent in multipara?, and at times the onset of the disease 
can be traced back to the puerperium. The formation of thrombi at the 



TUBERCULOSIS OF THE GENERATIVE ORGANS 



565 



placental site is believed to furnish an attractive resting-place for tubercle 
bacilli in the circulation. A tuberculous placenta may be the starting-point, 
and it is well known that a latent tuberculous process frequently lights up 
during pregnancy and the puerperium. 

Symptoms. — The symptoms are not pathognomonic of the condition, 
although the most frequent manifestation is a profuse and stubborn 
leucorrhcea. This symptom, when it occurs before puberty and after the 
menopause, may be particularly significant. The menstrual function may 
be normal, or scanty or profuse menstruation, or even amenorrhcea, may 
be observed. 

Treatment. — Whenever tuberculosis of the endometrium is strongly sus- 
pected, curettement should be performed immediately. As soon as the diag- 
nosis is made, unless the disease is discovered in the very early stages, and 
the tuberculous process appears to be limited to the superficial parts of the 
endometrium, panhysterectomy is indicated. For these cases discovered in 




Fig. 457- — Tuberculous pyosalpinx with torsion of ovary and tube. (University Hospital.) 

the earliest stage curettement may suffice. If the uterus is removed, both 
tubes should likewise be extirpated. One or both ovaries should, if possible, 
be allowed to remain. 



TUBERCULOSIS OF THE OVARY 

Pathology. — Tuberculosis of the ovary is somewhat infrequent. 
Ovarian involvement occurs in less than one-third of the cases of genital 
tuberculosis. Some authors report the percentage to be as low as 
12.6. In one or two reported cases tuberculosis of the ovaries appears to 
have been primary in origin. Infection may be hematogenous, or occur by 
direct extension from the Fallopian tubes and peritoneum. The latter is 
the commonest route. The infection may ako be carried to the ovary by 
way of the lymphatics. Tuberculosis of the ovary resembles tubercular 
infection of the testicle. In the early stages the disease in the ovary may be 
limited to the periphery, but later on the ovarian stroma is penetrated. 
There may be simple superficial tubercles or caseous foci, or ovarian ab- 
scesses the size of an egg may be seen. In the latter case, a mixed infection 






566 GYNECOLOGY 

has probably occurred. At times there is considerable enlargement of the 
ovary, without softening, the stroma of the ovary being infiltrated with 
yellow nodes. 

Symptoms. — The symptoms of tuberculosis of the ovary are not char- 
acteristic, and are usually combined with those of tubal or peritoneal 
tuberculosis. 

Treatment. — The treatment consists in extirpation of the diseased struc- 
tures. If the tuberculous disease is limited the ovary may be resected. 

TUBERCULOSIS OF THE CERVIX 

Pathology. — This is a rare form. Beyea was able to collect 69 cases. 
The cervix may be diseased without any other parts of the genital 
tract participating in the affection. In Beyea's collection of 69 cases 30 
were associated with far-advanced lesions of distant parts of the 
genital tract. In two primary cervical tuberculosis was discovered at 
autopsy. Twenty-two were clinical cases, and of these three were asso- 
ciated with lesions in other parts of the genital tract and in distant parts 
of the body. 

Symptoms. — The symptoms are not especially characteristic. As a rule, 
they consist of leucorrhoea, at times of an offensive odor, and metrorrhagia. 
Menstruation is generally profuse. The only positive method of determining the 
presence of a tuberculous lesion is by making a microscopic examination and 
by injecting fragments of the diseased tissue into guinea-pigs. 

The condition has often been mistaken for carcinoma or sarcoma, or has 
been erroneously classified as ulcer or vegetations. The disease may appear 
in the form of miliary tubercles scattered over the cervix, or as a papillary 
mass that resembles carcinoma or a tuberculous ulcer. 

Treatment. — The treatment will depend upon the associated lesions and the 
condition of the patient. If the disease appears to be restricted entirely to a small 
area of the cervix, a high amputation may be done. If the condition of the 
tubes is in doubt, it would be justifiable to perform an exploratory abdom- 
inal or vaginal section. In advanced cases panhysterectomy is the opera- 
tion of choice. 

TUBERCULOSIS OF THE VAGINA 

Pathology. — This is usually secondary, and associated with other tuber- 
culous lesions higher up in the genital tract. It may, however, be the only 
part affected, one case having been recorded in which a tuberculous ulcer 
of the vagina was primary. 

Symptoms. — The disease usually appears in the form of an ulcer. 
Tubercles are almost always present, however, on the floor of the ulcer or 
at the periphery. In the later stages ulceration is multiple, confluent, and 
displays a tendency to extend into the rectum or the bladder. The disease 
resembles carcinoma and syphilis, and a differentiation can be made only as 
the result of microscopic and bacteriologic examination. 

Treatment. — In mild cases destructive cauterization may suffice, but in 
more advanced cases radical excision may be demanded. 









TUBERCULOSIS OF THE GENERATIVE ORGANS 567 

TUBERCULOSIS OF THE VULVA 

Pathology. — The vulva is the most infrequent site of genital tuber- 
culosis. The rarity of a tuberculous infection of the external genitals 
has been used as an argument against a direct primary infection, but 
it is probable that the tubercle bacillus passes over the vulva to find a 
more fertile soil higher up. Many of the cases described in the literature as 
lupus, rodent ulcer, and esthiomene, are really tuberculous diseases of 
the vulva. 

Symptoms. — At first there is a dull red or livid discoloration of the skin, 
which is indurated, and slowly increases in size. After a variable length of time 
these tumor-like masses soften and break down, forming ulcers. These ulcers 
vary considerably in size, and are round, oval, or irregular in shape. The 
edges are infiltrated at first, but later become ragged and undermined. The 
base is uneven, granular, and covered with a yellow crust. Miliary tubercles 
are often seen about the borders. The ulcers do not bleed readily ; they 
advance slowly and heal irregularly. After a time, owing to coalescence, 
extensive destruction of tissue may take place, with the formation of 
fistula. In other cases there is great proliferation of tissue, with the pro- 
duction of nodules and polypi. If the disease involves the clitoris, this 
structure may be so much enlarged as to simulate elephantiasis. The in- 
guinal lymph-glands are not involved for some time. Pain is absent, the 
first symptom observed being, as in Kelly's case, pain on urination after a 
well-defined ulcer has formed. In many cases the disease is of such slow 
growth that it remains unnoticed for years. 

The syphilitic, chancroidal, and carcinomatous ulcers must be distin- 
guished. The differential diagnosis of syphilis may be made as the result of 
serum reactions and of anti-luetic treatment. In most cases a microscopic 
or bacteriologic examination may be necessary. 

Treatment. — The only treatment is complete excision. The Rontgen 
ray may be useful. 

BIBLIOGRAPHY 

Archambault, J. L, and Pearce, R. M. : " Tuberculose d'un adenomyome de l'uterus." Rev. 
d. gynec. e. d. chir. abd., 1907, xi, 3. 

Beyea, H. D. : " Tuberculosis of the Portio Vaginalis and Cervix Uteri, Its Pathology, 
Diagnosis and Treatment." Am. J. Med. Sci., 1901, cxxii, 612. 

Borchgrevixk : " Zur Kritik der Laparotomie bei serosen Bauchfalltuberkulose " Mitt, 
a. d. Grenzgeb. d. Med. u. Chir., Jena, 1000, vi. 

Bulkley, K. : "Tuberculosis of the Vulva." Am. J. Med. Sci., 1915, cli, 535. (Very exten- 
sive bibliography.) 

Hartz: " Uber die Tuberkulose der weiblichen Genitalorgane." Monats. f. Geburt. u. 
Gynak., xvi, 3. 

Hunner, G. L. : " Tuberculosis of the Urinary System in Women. Report of Thirty-five 
Cases." Johns Hopkins Hosp. Bull., 1904, 8. 

Konig : " Die peritoneale Tuberkulose und ihre Heilung durch den Bauchschnitt." Cent, 
f. Chir., Leipzig, 1900, xvii. 

Martin, A. : " Zur genitaltuberkulose." Berl. klin. Woch., 1908, xlv, 89. 

Mayo, W. J. : " Surgical Tuberculosis in the Abdominal Cavity with Special Reference to 
. Tuberculous Peritonitis." J. Am. Med. Asso., 1905, xliv; Ibid.: " Second a ry Tuber- 
culous Peritonitis, Its Cause and Cure." Trans. Sect. O., G. and A. S., A. M. A., 
1918, 72. 

Menge: "Tiber tuberkulose Pyosalpinx." Cent. f. Gyn., 1894, 24. 

Murphy, J. B.: "Tuberculosis of the Female Genitalia and Peritoneum." Am. J. Obst, 
1903, lxviii, 72>7\ 1904, lxix, 6 and 205. 



568 GYNECOLOGY 

Neff : " Resume of the Literature on Tuberculosis of the Peritoneum." Trans. South. 

Surg, and Gyn. Asso.. 1901, xiii. 
Schlimpert, H. : " Die Tuberkulose bei der Frau, inbesondere die Bauchfell — und die 

Genitaltuberkulose, die Tuberkulose des Uropoetischen Systems, die Tuberkulose 

wahrand Schwangerschaft und Wochenbett, auf Grund von 3514 Sektionen." Arch. 

f. Gynak., 191 1, xciv, 863. 
Shattuck: "On the Prognosis and Treatment of Tuberculosis Peritonitis." Amer. Med.. 

Phila., 1902. 
Taylor: "Tuberculosis of the Uterine Appendages.'' Trans. Sect. O.. G. and A. S., 

M. A., 1915, 88. 
Truesdale, P. E. : " Tuberculous Salpingitis." Trans. Sect. O., G. and A. S.. A. M. A., 

1913. 132. 
Williams, J. W. : " Tuberculosis of the Female Generative Organs." J. H. Hosp. Reports, 

1893, "i, 85. 
Wunderlich : " tiber die Misserfolge der operativen Behandlung der Bauchfelltuberku- 

ldse." Arch. f. Gynak., 1899, lix. 






CHAPTER XXXI 
SYPHILIS OF THE GENERATIVE ORGANS 

It is unnecessary in this volume to take up a general description of 
syphilis, or to discuss its nature, course, manifestations, or treatment. Only 
those facts that especially concern the female will be considered here. The 
excellent review of Gellhorn and Ehrenfest has been freely quoted from in 
this chapter. 

Syphilis is generally believed to be commoner among men than among 
women. From the statistics of Hubert, who studied the history of suspected 
cases and made routine Wassermann tests in all patients who came to his 
clinic, it appears that syphilis may be more prevalent among women than 
has heretofore been believed. Whereas in men the primary lesion is usually 
discovered by the patient or is readily detected by the physician, and 
whereas in men the primary sore leaves behind unmistakable traces that 
may persist for prolonged periods, the opposite is true in women. 

Several factors contribute toward making the demonstration of the initial 
lesion in women difficult : First, the female genitalia, being more complex 
than the male, the sore may develope in a hidden location and thus escape 
discovery. Secondly, in women the chancre does not present the typical in- 
duration with which we are familiar in male patients, unless it is situated 
on the cutaneous surfaces about the genitalia. When the primary sore is 
situated upon mucous membranes, there is usually no parchment-like in- 
duration of the base; its occurrence there is rare. Thirdly, the primary lesion 
clears up more rapidly in women than in men. In the former it is so 
transient that, given marked symptoms of secondary syphilis, the diagnosis 
is never uncertain even if one has failed to find the original sore. 

The general health of the patient is affected more in women than in 
men. Disturbed menstrual function, menorrhagia or metrorrhagia is fre- 
quently observed. Fever and anaemia are common. One of the striking 
differences is the greater frequency in men of paresis and tabes. This fact 
may possibly be explained on the ground that the thyroid gland is more 
active in females than in males, and that the principal secretion of the gland, 
i.e., iodothyrin, as is well known, in common with all iodine compounds, 
exerts a marked influence on syphilis. 

That women may be infected through the medium of the spermatic par- 
ticles is quite within the range of possibility. Neisser successfully inocu- 
lated the skin of monkeys with the parenchyma of the testicles of other in- 
fected monkeys. Finger twice succeeded in inoculating monkeys with the 
sperma of syphilitic men. 

" It is permissible to conclude that any part of the genital tract may be 
infected by the sperm, and that the syphilitic virus may reach even the 
peritoneal cavity by way of the tubes " (G. and E.). These deductions are 

569 



570 GYNECOLOGY 

not vitiated by the fact that spirochsetse have not yet been demonstrated in 
the testes of adult men, or by the acknowledgment of the fact that the virus 
may have been added to the sperma from a prostatic or urethral nidus 
of infection. 

As the spirochsetse are motile, it is conceivable that they may travel up- 
ward into the generative tract against the current caused by the cilia of the 
uterine and tubal mucosa. 

The variations in the local and general manifestations of syphilis give 
rise to the questions as to whether or not certain organs or tissues are more 
susceptible than others to luetic infection, and whether the spirochseta pallida 
shows a predilection for certain organs. Although these questions are un- 
answerable at present, it would seem possible that the variations are due to 
differences in the strains of the spirochsetse. The dearth of observations on 
luetic lesions of the internal genitalia in women, however, suggests that 
these structures are endowed with a relative immunity. 

The primary sore is the result of the introduction of the spirochseta 
pallida into a minute abrasion on a surface covered with squamous epithe- 
lium. The parasite shows a marked predilection for this type of epithelium, 
so marked, in fact, that chancres are almost never observed on other 
epithelial surfaces. A chancre exhibits the same structure wherever it is 
found, although it is subject to modification according to the tissue affected. 

" There is in the very early stages a new formation of capillaries, with an in- 
filtration about them of lymphocytes and plasma cells. In the early stage 
the infiltration is sharply limited ; in the later stages it is diffusely scattered 
throughout the corium. The endothelium of the capillaries is swollen and 
proliferated, so that the lumen is narrowed or altogether occluded, and the 
larger vessels, with an external coat, are increased in thickness. Sometimes 
giant-cells are found. The epidermis suffers secondarily, and presents a 
varied picture, such as atrophy, hypertrophy, erosion, or ulceration. From 
the newly formed granulation tissue connective tissue is produced which 
later scleroses and leads to fibrosis, interference with nutrition, and retro- 
gressive metamorphosis. Spirochsetae can always be demonstrated in the 
chancre by appropriate staining methods; of these, the new method by 
Levaditi seems to give the best results. Spirochsetse usually appear in 
enormous numbers between and within the cells" (G. and E.). 

There is little essential difference between the lesions of the three stages 
of syphilitic infection. " The microscopic picture of secondary syphilitic 
lesions reproduces that of chancre. The characteristic features are newly 
formed and dilated blood-vessels exhibiting changes such as those described 
above, and perivascular infiltrations with lymphocytes and plasma cells. 
Giant-cells are usually more abundant" (G. and E.). 

" Tertiary lesions differ from secondary ones only in the extent of granu- 
lomatous infiltration. This is satisfactorily explained by altered tissue reac- 
tion, the * Gewebsumstimmung ' of Neisser. Weakened by the long-lasting 
and all-pervading influence of the syphilitic virus, the tissues offer a less- 
ened resistance to the parasites, although the latter have greatly diminished 
in number " (G. and E.). 






SYPHILIS OF THE GENERATIVE ORGANS 571 

SYPHILIS OF THE VULVA 

Chancre of the vulva is so rarely observed that exact information as to 
its appearance is lacking. For that reason all cases should be described 
minutely and note made of variations in form. The primary sore in women 
may be considerably modified by the personal cleanliness of the woman and 
her habits. The most frequent seat of chancre, it is said, is the labia majora, 
the fourchette, nymphse, clitoris, and mons veneris being next in frequency 
in the order named. 

The primary sore is smaller and clears up more rapidly in women than 
in men. The so-called chancrous erosion is round or oval in shape, with a 
dusky-red areola and a shining raw surface, the center of which is covered 
with a gray, false membrane that is slightly moistened with a serosanguine- 
ous fluid. On a skin surface, as, e.g., the labia majora, induration developes 
in about a week and usually presents a parchment-like appearance. On 
modified skin surfaces near mucous membranes, for example, the labia 
minora or introitus vaginae, induration may be absent. The chancre may 
take the form of an ulcer (chancrous ulceration) with sloping edges, covered 
"with a gray, false membrane, and the seat of a serosanguineous discharge. 
A third variety of chancre, known as the indurated papule, consists of a 
hard, elevated, dusky-red tubercle, sharply defined from the surrounding 
tissues ; its surface is dry and frequently encrusted with layers of 
exfoliated epithelium, Fig. 168. 

The appearance of the chancre may be modified as the result of simple 
inflammation, chancroidal infection, traumatism, and the application of 
powerful antiseptics. 

When infection with chancroid and with syphilis takes place at the same 
time, the chancroid may heal before the chancre appears. As a rule, the 
chancroid persists and takes the form of a punched-out, sloughing ulcer, 
around which an induration gradually developes. When chancroidal virus is 
engrafted upon a well-developed chancre, a chancroidal ulceration takes 
place ; under such conditions the only indication of the earlier lesion is 
the induration. 

The secondary lesions on the vulva may appear as moist papules (mucous 
patch) or as broad, flat elevations, the result of hypertrophy of the papillary 
bodies of the skin ; these are known as condylomata lata. Condylomata 
lata are usually multiple, and frequently affect surfaces that are in apposi- 
tion, as, for example, the labia. Parts that are subject to the irritating influ- 
ences of heat and moisture are particularly prone to be affected. Associated 
with mucous patches there may be an abundant outgrowth of venereal warts 
These are due to irritation, and not to any specific virus. The secretions 
from condylomata lata or mucous patches are prolific sources of infection 
with the syphilitic virus, Fig. 170. 

Gumma of the vulva is rare. It usually developes in the labia majora, 
which becomes oedematous ; it has a tendency to break down and to suppu- 
rate. The differential diagnosis is often difficult to make. Ulceration fre- 
quently leads to the development of fistulae, Fig. 169. 



572 GYNECOLOGY 

SYPHILIS OF THE VAGINA 

The primary lesion of syphilis, the chancre, is rarely observed on the 
vaginal mucosa. When it appears here it resembles closely the primary in- 
durated ulcer seen elsewhere, except that the induration quickly disappears 
and but little scar tissue remains. The apparent rarity of the vaginal lesion 
may be due to the fact that it is overlooked in examination, to the absence 
of symptoms, or to the anatomic peculiarities of the vaginal tract, which 
usually presents no abrasions in which the spirochsetse may lodge. 

The secondary lesions of syphilis in the vagina are rare. Moist papules 
have been seen in the lower third of the vagina and also in the fornices, 
where their presence is probably the result of inoculation from a cervical 
lesion. These maculopapules are described as very small lesions, having a 
sharp outline, brownish red in color, and covered with a tenacious exudate. 

The tertiary lesion of syphilis, the gumma, is seldom found in the vagina. 
It rarely appears here except as the result of extension of a similar infec- 
tious process in a neighboring organ. 




Fig. 458. — Chancre of cervix, en- 
grafted on an erosion. (From Gellhorn 
and Ehrenfest, after Oppenheim.) 

SYPHILIS OF THE CERVIX 

Primary chancre of the cervix has very frequently been overlooked. 
Statistical reports show that of all primary chancres found on the genitalia, 
not over 1.5 per cent, are on the cervix. It is probable, how r ever, that primary 
chancre of the cervix occurs in from 4 to 10 per cent, of all cases of genital 
syphilis. It gives rise to no symptoms. It may affect either labium, but it 
has been more frequently found on the anterior lip. It may be engrafted 
upon an erosion due to a laceration, hence it is more frequent in parous 
women. Pregnancy and the congestion at the menstrual periods seem to 
favor the entrance of the spirochaetse (Figs. 458 and 459). 

A cervical chancre never presents a really characteristic or pathog- 
nomonic appearance, on account of its rapid and changing evolution from 
an uneroded induration to an ulcer that in turn either heals quickly or be- 
comes transformed into a simple erosion. 

As enlargement of the inguinal glands does not occur, and because of 
the difficulty in eliciting induration at its base, a suspicious-looking sore 
on the cervix can be identified as a primary hard chancre only if the 
spirochaeta pallida is recovered from its surface, and if the cervical lesion 



SYPHILIS OF THE GENERATIVE ORGANS 



573 



is followed in due time by a typical secondary exanthema. In those in- 
stances in which the cervical ulcer appears in conjunction with other typi- 
cal hard chancres in the vagina or on the external genitalia the presence of a 
multiplicity of initial lesions must be assumed. 

" Secondary syphilis manifests itself upon the cervix in the form of 
macules, papules, and ulcerations. These forms probably represent three 
successive stages in the development of a lesion caused by scattered accu- 




FiG. 459. — Chancre of cervix. 

(From Gellhorn and Ehrenfest, 

after Fournier.) 

mulations of the spirochaeta pallida in the squamous mucosa of the cervix. 
The parasite can be recovered readily from the secretion of any of the three 
forms, and this explains the great infectiousness of secondary lesions. 
Wassermann is positive in this stage. Macules and papules have no symp- 
tomatology of their own, while ulcers may give rise to profuse yellowish 
discharge. Occasionally a peculiar puffiness of the fornices (empatement) 




Fig. 460. — Secondary ulcer of pos- 
terior lip of cervix. (After Gellhorn 
and Ehrenfest.) 

may be present. The leucoplastic appearance of macules, the characteristic 
form of papules, and the typical yellowish color of ulceration render diag- 
nosis comparatively easy. Secondaries in other parts of the body form a 
valuable aid. Cervical lesions, as a rule, heal quickly and may disappear 
without leaving any trace. Specific treatment, energetically applied, brings 
about resolution in a very short time " (G. and E.) (Fig. 460). 

" The essential form of tertiary lesion of the cervix is that of a gumma, 
which, in the majority of instances, undergoes necrosis and ulceration. If 



574 GYNECOLOGY 

the tissue proliferation predominates, we speak of gumma ; if retrogressive 
changes prevail, we speak of tertiary or gummous ulcer. The process may 
involve the vagina or extend into the cervical canal, and is frequently asso- 
ciated with similar lesions elsewhere. The consistency is firm, but becomes 
soft under the influence of tissue necrosis. The most characteristic color is 
yellow, though various other shades may be observed. Bleeding or pro- 
fuse mucopurulent discharge is present in most cases, but no pain. These 
lesions, which may heal spontaneously, with the formation of scar tissue, 
disappear very quickly when specific treatment is instituted. Local treat- 
ment is altogether useless " (G. and E.). 

SYPHILIS OF THE UTERUS 

" Our knowledge concerning syphilitic lesions of the uterine body is ex- 
tremely meager. Primary and secondary manifestations have not yet been 
observed in the uterus, but a few instances of gumma in the uterine wall 
have been recorded. An isolated observation by Hoffmann proves the pos- 
sibility of gummatous changes taking place in the endometrium. This in- 
frequency of tertiary lesions is somewhat remarkable in view of the fact 
that the uterus, more than any other internal organ of the body, is exposed 
to direct infection. Spirochaetae may reach the uterine cavity by way of the 
vagina or from lesions of the cervix. Older writers have pointed out that 
in pregnancy the uterus is exposed to infection from the foetus, which 
acquired its syphilitic condition from the father. In the light of modern 
knowledge, however, in practically every instance the disease is known to 
be transmitted to the foetus from the mother, even though syphilis may at 
the time be latent in the latter. Aside from the question of paternal and 
maternal infection, it is certain that an actively syphilitic mother invariably 
infects the foetus. The logical conclusion to be drawn is that in every 
pregnant syphilitic woman spirochaetae must be present in the maternal 
portion of the placenta, i.e., the endometrium. The finding, by 
Huebschmann, of spirochaetae in the decidua prove this point. Unless, as 
Whitehouse suggests, syphilitic lesions of the uterus have been overlooked 
in the past, we are forced to assume that a relative immunity on the part of 
the uterus exists. It is a very striking fact, says Pusey, in view of their 
being purely genital structures, that the body of the uterus and its analogue 
in the male, the prostate, are probably the most rarely involved of any 
structures in the body affected by tertiary syphilis " (G. and E.). 

SYPHILIS OF THE TUBE 

" It seems possible that the tubes may be the seat of luetic lesions, but 
the pathologic and clinical material on record is yet too incomplete to per- 
mit of positive assertions. Spirochaetae have never been found in the tubes 
of syphilitic women " (G. and E.). 

SYPHILIS OF THE OVARY 

" Various changes in the ovaries (simple enlargement, syphilitic oophor- 
itis, tertiary sclerosis of ovary, ovarian gumma) have been described as 
typical expressions of the secondary and tertiary stages of luetic infection, 



SYPHILIS OF THE GENERATIVE ORGANS 575 

but in no instance (with the possible exception of Hoffmann's case) has 
positive proof been furnished that such alterations are actually due to a 
local luetic process. 

" The fact that in some syphilitic patients either an amenorrhoea or, 
more commonly, a metrorrhagia, disappears after specific medication can- 
not be accepted as evidence of a syphilitic ovarian lesion. Spirochetal 
have as yet not been demonstrated in the ovaries of adults" (G. and E.). 

SYPHILIS OF THE CELLULAR TISSUE 

" Syphilis of the pelvic cellular tissue appears in the form of a diffuse 
gummatous infiltration which secondarily involves the pelvic peritoneum " 
(G. and E.). To the few cases on record a personal observation by 
Gellhorn and Ehrenfest has been added. In almost all instances a wrong 
diagnosis of malignancy has been made. In the case of Gellhorn and 
Ehrenfest the positive outcome of the Wassermann reaction, together with 
other unmistakable signs of tertiary syphilis about the outer genitalia, aided 
in establishing the correct diagnosis. " Specific treatment produces amaz- 
ingly quick improvement of an apparently hopeless condition " (G. and E.). 

DIAGNOSIS OF SYPHILIS OF THE GENITAL TRACT IN WOMEN 

An absolute diagnosis of the syphilitic nature of an ulcerative lesion of 
the genitalia can be established only as the result of the demonstration of 
spirochete in the secretion. The large percentage of women afflicted with a 
latent syphilis and giving positive Wassermann reactions must, to a certain 
degree, lessen the value of this test as confirmatory of syphilis being the 
cause of ulcerative lesions about the external genital tract. 

Syphilitic lesions of the vulva must be differentiated from herpes genitalis, 
lupus, esthiomene, condylomata acuminata, chancroid, and gonorrhceal macule. 

Syphilitic lesions of the vagina must be differentiated from herpes geni- 
talis, ulcerative processes following the prolonged and continuous wearing 
of a pessary, ulceration from the use of caustic drugs, aphthous ulcers, and 
various forms of vaginitis that may show a tendency to produce discrete 
ulcerative lesions and malignant conditions, such as carcinoma. 

Syphilitic lesions of the cervix must be differentiated from simple ero- 
sion, chancroid, tuberculous ulcer, gonorrhceal macule, herpes genitalis, 
aphthous ulcers, carcinoma of the cervix, and perhaps cervical polyp 
and fibroids. 

DIFFERENTIAL DIAGNOSIS OF SYPHILITIC LESIONS OF THE CERVIX 

" The prototypes of the three stages of syphilitic infection, the chancre, 
the macule or papule, and the gumma, offer no particular difficulty to the 
diagnosis, but ulcerative changes are apt to obscure their characteristic 
features. It may, then, be helpful to remember certain general character- 
istics of luetic lesions of the cervix, viz.: 

"(a) Specific ulcers, as a rule, produce very little secretion; only exten- 
sive tertiary ulcers or necrotic gummata cause a pathologic discharge. 

"(b) There is no pain, either spontaneous or on touch. 



576 GYNECOLOGY 

"(c) Luetic lesions are frequently at some distance from the external os, 
which hardly ever occurs in non-specific ulcerations of the cervix. 

"(d) Syphilitic ulcers are characterized by their sharp outline. 

"(e) Syphilitic ulcers are usually covered with a film-like deposit which 
may be wiped off easily and exhibits a characteristic fatty luster. 

"(/) Syphilitic ulcers show very little, if any, inflammatory reaction of 
the surrounding mucosa. 

" These common characteristics, however, may be invalidated to a lesser 
or greater degree by pregnancy, lacerations, coexisting inflammations, or 
local applications. Thus Mehanos speaks of the misleading fatty luster 
produced on erosions by the use of caustics. 

" In the diagnosis of the primary lesion the demonstration of the 
spirochaetae pallida is the prime requisite. Next in importance is the char- 
acteristic induration of the base, if present. Wassermann is as yet negative. 
The appearance, in due time, of typical secondaries clinches the diagnosis. 

" The diagnosis of secondary ulcerations is based primarily upon the 
presence of the specific parasite. The positive outcome of the Wassermann 
reaction is a highly suggestive, but not a conclusive, aid in the diagnosis. 
The history of infection, coexisting secondary lesions in other parts of the 
body, and the prompt effect of specific treatment are contributory factors. 
Occasionally exploratory excision and microscopic examination may be 
found necessary. 

" Tertiary lesions may so quickly develop from secondary ulcerations 
that differentiation between the two stages may not always be possible. 
Spirochetal are not found in the secretion. Wassermann may be negative, 
especially if the infection has occurred a long time previously. As a rule, 
other tertiary manifestations are present. The actual findings and the im- 
mediate effect of specific treatment will establish the diagnosis. Microscopic 
examination is frequently a conditio sine qua non " (G. and E.). 

Chancroid. — Chancroids are, as a rule, multiple. A chancroid of the 
cervix is usually complicated by a similar lesion on the external genitalia. 
In contrast to the well-defined contour of a syphilitic ulcer, the edges of the 
lesion are usually irregular, notched, and undermined, and the base is 
granular and uneven. The secretion contains the bacillus of Ducrey. The 
regional lymph-glands are always infected. 

Tuberculous Ulcers. — Tuberculous ulcers are regular in shape, their edges 
heing thinned out and deeply undermined. The most important distinction 
between tuberculous ulcers and syphilitic lesions is found in the marked 
tenderness of the former. 

Gonorrhoeal Maculae. — " Syphilis and gonorrhoea are so frequently com- 
bined in the same individual that the differentiation of gonorrhoeal macules 
from macular syphilids is of great practical importance. Gonorrhoeal maculae 
are less distinctly outlined, vary in size, often forming ill-defined, confluent 
blotches. Their color is lighter than that of the syphilitic maculae, appear- 
ing as a bright yellowish red. Usually they are lying flat in the level of the 
mucosa, but they may be elevated, especially when their surface becomes 
granular, indicating the beginning of a transformation into a condyloma 



, 



SYPHILIS OF THE GENERATIVE ORGANS 577 

acuminatum. In this form the gonorrhoeal lesion resembles the luetic papule, 
which, however, is well distinguished by its flat top " (G. and E.). 

" Herpes genitalia is very rarely observed on the cervix. It manifests 
itself in the form of single or grouped minute vesicles, with either clear or 
purulent contents. Each vesicle is surrounded by a bright red zone of in- 
flammation. The vesicles are apt to form polycyclic figures. As a rule, 
they soon rupture and change into superficial erosions, which preserve a 
polycyclic arrangement. When infected, they lead to the formation of 
aphthous ulcers " (G. and E.). 

Aphthous Ulcers. — " These have a smooth surface and are covered with 
a yellowish-white, adherent pseudomembrane. In this form they closely 
resemble small secondary ulcers or even small primary chancres. Oppen- 
heim emphasizes as a distinguishing feature the firmness with which the 
covering film adheres, and the distinctness of the surrounding reactive zone 
in the mucosa." 

Myoma. — " Occasionally an intact gumma of the cervix may simulate a 
fibroid." In one case of Gellhorn and Ehrenfest a nodule in the cervix of a fibro- 
matous uterus was recognized as a gumma only upon microscopic examination. 

Carcinoma.—" The correct differentiation between syphilis and car- 
cinoma of the cervix is by far the most important problem to be discussed 
here." Hysterectomies or amputations of the cervix have been done in cases 
where later developments demonstrated the presence of syphilis. In some 
instances the error in diagnosis was not recognized until the patient was on 
the operating table. 

" The similarity of the two affections is indeed striking if the lesion 
appears in the form of a cauliflower growth ; or if a chancre is located within 
the external os, as described by Mrazek, and causes sloughing of the lower- 
most part of the cervical canal. 

" Neumann believes that infiltration of the parametrium and immo- 
bilization of the cervix are common in cancer and rare in luetic ulcers, even 
in advanced necrotic gummata. It has frequently been stated that cancer 
bleeds easily, as contrasted with luetic ulcers, and while this may be true 
in a general way, there are exceptions. Suspicious ulcerations upon the 
cervix which are separated from the external os by a zone of normal mucosa 
are more likely to be of a luetic nature. 

" The final diagnosis, however, will depend upon the microscope. 

" A search for spirochsetse should be made in every doubtful instance. 
Dark-field examination is superior to other methods, as it enables us to dis- 
tinguish between the spirochseta pallida, on one hand, and the spirochseta 
refringens and balanitidis, on the other. The two last-named are commonly 
found in the vagina and occasionally on necrotic cancers. 

" In daily practice the proposition amounts to this : The overwhelming 
majority of cancers present themselves in an inoperable state. If there be the 
slightest doubt as to the true nature of the disease, an attempt with anti- 
luetic treatment should be made. We know that syphilitic lesions respond 
very promptly to appropriate treatment, and, therefore, not much time would 
'have been wasted even if specific therapy proved to be a failure " (G. 
and E.). 
37 



578 GYNECOLOGY 

Prognosis of Syphilitic Conditions of the Genital Tract in Women. — 

The prognosis is favorable, the disease is quickly controlled, and the 
progress toward healing may be gauged not only by inspection and symp- 
tomatology, but also by the serum reactions. 

Treatment. — A cure may be effected by the use of arsphenamine (sal- 
varsan), neoarsphenamine (neosalvarsan), mercury, and the iodides, either 
alone or supplementing one another. 

BIBLIOGRAPHY 

Gellhorn, G., and Ehrenfest, H. : " Syphilis of the Internal Genital Organs in the 
Female." Am. J. Obst., 1916, lxxiii, 864. (With complete bibliography.) 



CHAPTER XXXII 
DISORDERS OF MENSTRUATION 

The physiology of menstruation has previously been considered. 
Its phenomena depend upon processes involving chiefly the ovaries and 
the uterus ; from this it follows that abnormalities of these organs, 
whether of a congenital or an acquired nature, may alter the menstrual 
phenomena in various ways. The menstrual function • is influenced 
also by the glands of internal secretion, the central nervous system, and the 
general health ; it may be modified, therefore, by abnormal functions of the 
ductless glands, nervous disorders, and constitutional diseases. The men- 
strual phenomena may vary considerably in different individuals within 
physiologic limits. Thus, while early puberty usually denotes hyperfunc- 
tion and late puberty hypofunction of the ovaries, etc., either condition may 
occur without manifesting any apparent defect in the general health, 
physical characteristics, or reproductive powers (see Physiology, Chapter IV). 

The menstrual flow most commonly recurs every twenty-eight days, but 
it may vary in periodicity from twenty-one to thirty days. 1 The duration 
may vary from two days to a full week, and the amount of menstrual blood 
lost may vary from a scant flow, sufficient to soil but a few napkins a day. 
to a profuse discharge requiring from eight to ten. Either extreme 
may occur in a woman who may be free from illness or disturbance of any 
kind. Of course, those who present variations from the common menstrual 
type more frequently exhibit pathologic states, local or general, than those 
in whom menstruation recurs every twenty-eight days and persists for the 
usual time. Nevertheless, the menstrual habit, or custom of the individual, 
may deviate considerably from the common type, and the subject still be 
entirely normal. 

PRECOCIOUS MENSTRUATION 

When puberty begins before the usual period, menstruation is said to be pre- 
cocious. Those in whom this phenomenon appears show physical and mental in- 
dications of sexual maturity beyond their years. In some cases the condition 
appears to be due to an abnormal development and hyperf unction of the ovaries, 
and in others sarcoma of the ovary has been found. In some cases a pathologic 
condition of the pineal gland has been held responsible for the condition. Occa- 
sionally the subjects have been hydrocephalic or rachitic. Hemorrhages from the 
uterus have been known to occur during the first few weeks of life, but this 
is not regarded as precocious menstruation, but rather an evidence of a 
stimulation of the endometrium by the hormones in the mother's milk. 
Forty-four cases of precocious menstruation have been collected by Ploss, 
the youngest patient being two months old. 

3 Twenty-eight-, thirty- or twenty-one-day type in 83 per cent, of cases. (K. Das.) 

579 



580 GYNECOLOGY 

DELAYED MENSTRUATION 

Menstruation may be regarded as delayed when it does not appear until 
after the usual age of puberty. This condition is normal in certain indi- 
viduals, and may have no significance, or it may indicate a general lack of 
development of the generative organs, hypofunction of the ovaries, or in 
some cases disease of the pituitary gland or general ill health. 

VICARIOUS MENSTRUATION 

In some instances hemorrhage from mucous membranes other than the 

endometrium has been observed at the time of the menstrual flow ; this is 
termed vicarious menstruation. It most frequently takes the form of epistaxis. 

AMENORRHCEA 

An absence of the menstrual flow during the reproductive period from 
puberty to the menopause, except during pregnancy or lactation, is abnor- 
mal, and is due to pathologic causes, either general or local. 

A pseudo-amenorrhoea may exist in which the patient exhibits the gen- 
eral signs of menstruation, without any external evidence of a menstrual 
flow; this is due to an obstruction in the genital canal. Under such circum- 
stances the menstrual fluid is pent up behind the point of obstruction, con- 
stituting a form of gynatresia (see Developmental Anomalies and Malfor- 
mations, Chapter II). 

Etiology. — Amenorrhcea is dependent upon various conditions, and may 
be classified as anatomic, constitutional and psychic. 

Anatomic Defects Producing Amenorrhcea. — These pertain particularly 
to the ovaries and the uterus. If the ovaries are well developed and the 
uterus is rudimentary or absent, the ovarian influence is normally present but the 
uterus is unable to respond in the usual way, and the menstrual flow may either 
be very scanty or be absent altogether. When these conditions obtain, the 
patient usually suffers severely from the general phenomena of menstrua- 
tion, which are known as the molimina mcnstrualia. 

When the conditions are reversed, that is to say, when the uterus is 
well developed but the ovaries have undergone degeneration or are poorly 
developed, the menstrual impulse is weaker than normal, and may be insuffi- 
cient to produce a menstrual discharge. Total absence of menstruation, 
however, with a well-developed uterus, is quite unusual, although not infre- 
quently both the uterus and the ovaries are poorly developed and the men- 
strual discharge is irregular and scanty. 

Amenorrhcea of a more or less marked and persistent type may occur 
from acquired lesions that involve both ovaries extensively; for example, 
bilateral cystic or solid tumors of the ovary of a malignant type, or of the 
type that destroys the ovarian parenchyma. Inflammation of the ovary 
complicating mumps is at times responsible for an abrogation of the men- 
strual flow, and certain cases of atrophy of the ovary have been attributed 
to ovaritis complicating small-pox and scarlet fever. Amenorrhcea may also 
be due to hyperinvolution of the uterus, the result of prolonged lactation, or 



DISORDERS OF MENSTRUATION 581 

may be traceable to septic postpartal infection with resulting sclerosis. In 
some cases repeated or excessive curettage of the uterus destroys the endo- 
metrium beyond the power of sufficient regeneration, and scanty menstrua- 
tion or a partial amenorrhoea may result. Amenorrhoea is sometimes ob- 
served coincident with, or subsequent to, a general increase in fat at about 
the age of thirty (see Premature Menopause, p. 594). It has been stated 
that female morphine habitues do not menstruate. 

Constitutional Diseases Producing Amenorrhoea. — It is natural that the 
most prominent general diseases in which scanty or absent menstrual flow 
is a symptom should be those that affect the blood. The most common of 
these is chlorosis. According to Virchow, in chlorotic girls not only the 
blood, but the entire circulatory apparatus, is defective, and this results in 
faulty development of the genitalia at the time of puberty. Stieda regarded 
chlorosis as an occasional sign of degeneracy, placing it in the same category 
with infantile genitalia, infantile pelvis, or abnormalities of the cranial bones. 
Chlorosis may be attributable to outside influences ; that is to say, improper 
hygiene, etc., although chlorotic individuals usually show other evidences 
of physical defects. Chlorotic girls do not invariably suffer from amenor- 
rhoea, but may occasionally have a profuse menstrual flow. In some cases 
the ovaries are unusually large. 

After the depressing general influence of certain infectious diseases, such 
as typhoid fever, amenorrhoea may be present for a time. It may also be 
observed in tuberculosis, Basedow's disease, diabetes, malignant growths, 
chronic gastritis, and leucaemia. Amenorrhoea may be one of the earliest 
symptoms of acromegaly or of Addison's disease. 

Psychic Influences Producing Amenorrhoea. — The psychic influences that 
produce amenorrhoea are hope and fear ; that is to say, there may be some delay 
in the appearance of the menstrual flow in a woman who desires pregnancy or in 
one who fears it. Such instances are exceptional, however, and the delay does 
not usually cover more than a week. Cases are on record in which a terrible 
fright or a fearful catastrophe has produced amenorrhoea, but in such instances 
it is likely that the cessation of the menstrual flow is only one of the manifesta- 
tions of mental and physical disaster. A change of climate or altered social 
relations are frequently responsible for temporary amenorrhoea. 

In a few cases the exact cause of amenorrhoea cannot be determined 
positively. The menstrual flow may cease suddenly in women who other- 
wise show no derangement in health. Such women may exhibit none of the 
accepted causes of amenorrhoea, even upon the most careful examination, 
and after a certain time menstruation may be resumed without any treat- 
ment, and with no more apparent reason for its resumption than for 
its cessation. 

Treatment. — It is always desirable to endeavor to find a cause for amenor- 
rhoea before resorting to any definite or prolonged plan of treatment. If the pa- 
tient has passed the age of puberty without ever having menstruated, or if she has 
had recurring subjective symptoms of menstruation without a menstrual 
flow, it may be advisable to make an immediate pelvic examination. As 
these patients are young, nulliparous women, the examination should in- 
variably be made under anaesthesia. If there are no painful menstrual 



582 GYNECOLOGY 

molimina, but if evidences of ill health are apparent, this examination need 
not be insisted upon at once, but the general condition of the patient may be 
improved in the hope that the function will be established normally. 

In chlorotic patients the use of iron, arsenic, and cod-liver oil, regulation 
of the diet, abundant exercise in the open air, and general improvement of 
the hygienic conditions should be immediately instituted. 

When amenorrhoea is apparently due to psychic influences, much can be 
accomplished by suggestion, and in case pregnancy is feared, by the absolute 
assurance that pregnancy does not exist, or by reassuring the patient upon 
any other point upon which the mind has dwelt. When general measures 
do not result speedily in the resumption of the menstrual flow, a careful ex- 
amination should always be made in order to exclude the commonest cause 
of amenorrhoea — namely, pregnancy. This Avill usually be true only of 
patients who have already started to menstruate, and in whom the amenor- 
rhoea might be said to be acquired ; pregnancy is not likely to be the cause of 
the delayed appearance of the function of menstruation. 

Pregnancy must always be positively excluded before prescribing any 
drugs that have, or are believed to have, a direct stimulating effect upon the 
menstrual flow. At the time of the examination, the cause of the amenor- 
rhoea may be ascertained by finding that the uterus or the ovaries are 
imperfectly developed. The defect may be more in the nature of an under- 
development than of an actual deformity. In the first instance, if the uterus 
is well shaped and of fair length, and if the cervical canal is patulous, toning 
up the general health may result in marked improvement, especially if a 
beginning is made during adolescence. In many cases of functional amenor- 
rhoea due to insufficient ovarian development the administration, by the 
mouth or by hypodermic injection, of extracts of ovarian substance or of the 
corpus luteum of the cow or sow will stimulate the ovarian secretion or 
assist it to such a degree that a practically normal flow will ensue. The 
most satisfactory preparation is said to be the freshly prepared extract of 
the entire ovary. Either this or the extract of the corpus luteum may be 
given in doses of from 2 to 5 grains three or four times a day. The extracts 
of the other glands of internal secretion may sometimes be advantageously 
combined ; thus thyroid extract, ^ to 2 grains three times daily, or the 
extract of the anterior lobe of the pituitary gland may be used in cases 
associated with adiposity. 

In older women, and in younger ones if general treatment does not 
suffice, the intrauterine application of the galvanic current may be em- 
ployed, or an intrauterine stem may be inserted. When the uterus is 
very small — distinctly below normal in size — and irregular in shape ; when 
the cervical canal is extremely narrow ; when the cervix is poorly developed 
and the ovaries are small or cannot be recognized by bimanual palpation, 
the outcome of any form of treatment is exceedingly doubtful, and in a ma- 
jority of cases not much can be achieved. 

If the ovaries are sufficiently developed to give a decided menstrual im- 
pulse and the uterus is so defective that no menstrual flow is possible, the 
recurring subjective symptoms may be so painful as to require extirpation 
of the rudimentary uterus with conservation of the adnexa. When preg- 



DISORDERS OF MENSTRUATION 583 

nancy can be excluded, and after general measures have been instituted, 
emmenagogues or drugs that are said directly to stimulate the menstrual 
flow may be prescribed. Cantharides, black oxide of manganese, savin, rue, 
tansy, pennyroyal, and apiol are believed to stimulate the menstrual flow. 
Dewees' emmenagogue mixture, which consists of cantharides in combina- 
tion with iron, aloes, and guaiac, is one of the most effective formulae. 

If pregnancy exists, these drugs will usually have no effect in bringing 
on the menstrual flow. They may be used as an added stimulant to the 
menstrual impulse after general and hygienic measures have been adopted, 
but they should never be pushed beyond the physiologic dose. It is to be 
understood that what has been said in relation to amenorrhcea applies 
equally to an absolute non-appearance or abrogation of the menstrual flow, 
to delay in the monthly recurrence, and to a diminution in the amount of the 
menstrual discharge. 

MENORRHAGIA 

Etiology. — Menorrhagia, or an increase in the amount or in the dura- 
tion of the menstrual flow, may be due to an excessive ovarian impulse, to 
an enlargement of the area in the uterus that responds to the impulse, or to 
any local or general condition that produces congestion of the blood-vessels 
of the uterus and the endometrium. 

In some women the menstrual flow is naturally profuse without any 
gross lesion being present ; in these cases the condition is probably an evi- 
dence of hyperf unction of the ovaries. The flow may recur at periods of 
from twenty-one to twenty-five days. This may be within the bounds of 
health, and may have no pathologic significance. Such women are usually 
large and of the plethoric type. Excess of the ovarian impulse may be 
found in conjunction with such local conditions as prolapse, simple reten- 
tion cysts, or cystic degeneration of the ovaries. An increase in the surface 
that sheds the menstrual blood and a congestion of the endometrial vessels 
are found in such local lesions as hypertrophy of the endometrium, chronic 
metritis, subinvolution, retro flexio-version or prolapse of the uterus, adenoma 
or polyp of the endometrium, myoma, sarcoma, and carcinoma of the uterus. 

The general causes of menorrhagia are frequently overlooked. Among 
the general causes of pelvic congestion predisposing to menorrhagia may 
be mentioned cardiac insufficiency, cirrhosis of the liver, and chronic 
nephritis. Menorrhagia may be a manifestation of hemophilia and scurvy, 
and be the direct result of alterations in the venous and arterial walls. The 
frequent occurrence of menorrhagia or metrorrhagia in connection with a 
positive Wassermann reaction is responsible for the belief that numerous 
cases of intractable uterine hemorrhage may be attributed to syphilitic 
changes. Since, however, a large number of cases are found in non-luetic 
women, and in many no benefit follows anti-syphilitic medication, it is 
doubtful whether local alterations are as largely responsible for uterine 
hemorrhage in a syphilitic as is the general effect of the disease upon the 
system as a whole, reflected in disordered ovarian and uterine function. So, 
too, the amenorrhcea of secondary syphilis may logically be ascribed to a 
luetic anaemia or secondarv dvsfunction of the ovaries. 



584 GYNECOLOGY 

Menorrhagia is also at times associated with certain acute diseases, such 
as typhoid fever, cholera, variola, scarlatina, influenza, and acute articular 
rheumatism. This may be explained either on the ground of a general im- 
pairment of the circulatory force, such as is commonly observed in the course 
of these diseases, or possibly by an exanthematous involvement of the 
uterine mucosa. 

Menorrhagia appears at times to originate in nervous influences affecting 
the vasomotor svstem. Thus a fright or any mental shock mav result in 
menorrhagia. It is observed in hysteria and neurasthenia. It is just as 
reasonable to believe that impulses from the central nervous system may 
alter the normal menstrual function of the uterus as it is to believe that the 
pains of labor are affected by psychic impressions. 

Noble has tabulated the common causes of menorrhagia according to the age 
and social condition. While it is our belief that in young virgins disorders of 
ovarian function or a disarrangement of the coordination in function of the 
glands of internal secretion are chiefly responsible for menorrhagia, Noble de- 
clares that it may be due to a disturbance of the vasomotor system and a 
lack of vasomotor stability, caused by the active growth that sometimes takes 
place about the time of puberty. It is quite evident that the vasomotor instability 
may be secondary to the derangement in the glands of internal secretion. 

Menorrhagia in a child-bearing woman is most frequently due to some 
complication of pregnancy, labor, or the puerperium. Subinvolution and 
displacement of the uterus, adnexal inflammation, retention within the uterus 
of decidua or placenta, and severe lacerations of the cervix, with subsequent 
hypertrophy and chronic congestion, are most frequently responsible for the 
hemorrhage. In unmarried women, especially in those approaching the 
age of forty, myomata or an endometrial polyp will frequently be found. 
Malignant disorders must always be suspected and be carefully excluded 
before any plan of treatment is adopted. 

Treatment. — Except in young unmarried women, a pelvic examination is al- 
ways imperative before any form of medication is adopted. This rule becomes 
increasingly important with advancing years. The treatment of menorrhagia, 
therefore, depends upon the underlying condition. The relaxed, overgrown 
young woman should be carefully instructed in hygienic regulations, diet, 
and exercise, and suitable tonics should be prescribed. Hypodermic injec- 
tions of extracts of the pituitary gland at intervals of several days may be 
found of service. In such cases when menorrhagia is accompanied by 
leucorrhcea, hyperplasia of the endometrium may be suspected, and curette- 
ment employed as a curative measure. A subinvoluted uterus should be 
depleted by hot douches, glycerine tampons, or curettement ; displacements 
of the uterus should be corrected ; chronic constipation should be overcome ; 
cervical lacerations should be repaired or exposed to local depletory meas- 
ures ; myomata, endometrial polyps, and malignant growths should be ex- 
posed to operation ; enlargement of the ovary, with a persistence of menor- 
rhagia, would usually justify an exploratory abdominal incision. 

If no local lesions to account for the symptom are found or if, in addi- 
tion to the local lesion, or without it, a defect in the circulation is demon- 
strable, as evidenced by cardiac lesions, contracted kidnev, cirrhotic liver, 



DISORDERS OF MENSTRUATION 585 

varicose veins in the lower extremities, hemorrhoids, swelling of the ankles, 
dyspnoea, and palpation, the use of digitalis and strychnine will do much to 
diminish the amount of flow. 

Ergot, given by mouth or by hypodermic injection, is universally em- 
ployed to control the hemorrhage ; this it does by increasing the contractions 
of the uterus ; it may be combined with hydrastis and its derivatives. 
Stypticin has been of no particular advantage. It is an expensive remedy, 
and, according to Boldt, to be effectual it must be given in very large dose — 
from i to 5 grains every two to eight hours. The following prescription of 
ergotin (Bonjean's), digitalis, and powdered hydrastis is one of the most 
effectual combinations: 

f£ Ergotin. (Bonjean's) gr. ij 

Pulv. ext. digital gr. 1/6 

Pulv. hydrast gr. iij 

q. 3 hrs. 

In some cases, as previously noted, hypodermic injections of extract of the 
pituitary gland may prove effective. Bab reports very favorable results from the 
use of pituitrin. The intrauterine application of radium is almost invariably 
effective in checking the recurrence of profuse menorrhagia. It acts by 
causing obliteration of some of the endometrial capillaries. The Rontgen 
ray is also effectual. Its favorable influence, it is presumed, is the result of 
an impairment of follicular development, and hence there is a decrease in 
the ovarian impulse. 

The Rontgen ray must be used guardedly. It affects particularly the 
follicle-bearing area of the ovary, and undue exposure may result in an 
entire destruction of the ovarian function (see Radium and Rontgen Ray 
Therapy, Chapter XL). 

Much can be done for patients the subjects of menorrhagia by having 
them rest during the menstrual period. In serious cases the movements 
should be restricted absolutely, the patient being kept in bed for from a day 
or so before the time at which the flow is due until the usual period is past. 
The application of an ice-bag to the abdomen may assist in reducing the 
flow. Before the expected time for the flow the bowels should be thoroughly 
moved by saline laxatives. 

METRORRHAGIA 

Etiology. — Metrorrhagia, or bleeding between the menstrual epochs, 
is caused by many of the conditions that produce menorrhagia. As a rule, 
the underlying cause is further advanced and more pronounced than in the 
case of menorrhagia. In addition, bleeding between the periods is more 
often indicative of malignant lesions, such as carcinoma or sarcoma, and also 
of tubal pregnancy, myomata that have caused pressure atrophy or ulcera- 
tion of the uterine mucosa, cystic glandular endometritis, and endometrial 
polyp. Metrorrhagia due to lesions of the myometrium (myopathic metror- 
rhagia), such as chronic metritis, fibrosis of the uterus, arteriosclerosis of 
the uterine vessels, etc., is observed in women who are approaching 
the menopause. 



586 GYNECOLOGY 

Treatment. — In treating a case of metrorrhagia the first aim of the physician 
should be to discover its cause. In patients past the age of thirty-five the possi- 
bility of carcinoma or sarcoma should be borne in mind, and care must be 
taken to exclude or confirm this possibility by the diagnostic methods already de- 
scribed (Malignant Tumors of the Uterus, Chapter XVIII). When the metror- 
rhagia has been extremely severe and the patient is suddenly weakened from loss 
of blood, it may be desirable to take immediate steps for relief, such as rest in bed, 
the application of cold to the lower abdomen, and the exhibition of horse serum. 
It may also be wise to pack the vagina, or in some cases the uterus, 
wath gauze ; it is very rarely necessary to pack the uterus if the vaginal vault 
is snugly filled with gauze disposed in a circular manner about the cervix, 
so as to cause compression and occlusion of the cervical canal. Such a 
vaginal pack, combined with a suprapubic pad and binder, will, in a ma- 
jority of cases, be effective. A uterine pack should not be carried out with- 
out complete aseptic precautions. As a rule, rest in bed, an ice-bag applied 
to the lower abdomen, and a vaginal pack after a copious douche of hot 
water will control hemorrhage. The treatment with drugs is similar to that 
described for menorrhagia. 

For the more chronic cases, the exciting cause, whatever it may be, 
should be removed — that is to say, an endometrial polyp, a thickened endo- 
metrium, or a submucous myoma should be treated operatively. Myoma 
of the uterus, carcinoma, uterine displacement, and pelvic inflammatory dis- 
ease should be dealt with in the usual way. 

Difficulty in the treatment of metrorrhagia is encountered chiefly in 
those cases in which the bleeding is evidently myopathic (uterine fibrosis, 
arteriosclerosis, etc.) in origin, or is due to such general lesions as hemo- 
philia, lymphatic obstruction, chronic nephritis, arteriosclerosis, cirrhosis 
of the liver, etc. In such cases any surgical treatment short of hysterectomy 
is of little avail. 

In radium and the Rontgen ray, but especially in radium (see Radium 
and Rontgen Ray Therapy, Chapter XL), we have a certain and effectual 
means of giving relief. When malignant disease of the uterus and adnexa can be 
excluded, radium is the remedy par excellence. It may also be used when the pa- 
tient's condition is such as to preclude operation, even though surgical interven- 
tion is otherwise indicated. After the hemorrhage is controlled, the patient's con- 
dition improves and then the operative procedure may be carried out. 

When menorrhagia or metrorrhagia is caused by visceral lesions asso- 
ciated with high blood-pressure, caution must be used in the employment of 
radium or of any other measure to check the bloody flux ; for the latter may 
be of actual benefit to the patient and for the time being at least prevent a 
rise of the blood-pressure in the arteries to the breaking point. If the patient 
is not suffering from the loss of blood (anaemia-asthenia, etc.), diagnostic 
curettage should be done in order to determine that no malignant condition 
is present in the uterus. When this has been assured, general measures to 
reduce the blood-pressure should be instituted, but neither local nor oper- 
ative treatment to check the flow should be undertaken. 



DISORDERS OF MENSTRUATION 587 

DYSMENORRHEA 

A woman is said to be suffering from dysmenorrhoea when the sub- 
jective manifestations of the menstrual period are so exaggerated that 
she complains of marked pain or discomfort in the lower abdomen 
and pelvis, thighs., or sacral region. Severe headache, occurring regu- 
larly at the menstrual periods, whether or not accompanied by pain elsewhere, 
may be considered a form of dysmenorrhoea, although in many instances its 
relation to the menstrual process is not entirely clear. 2 

Severe dysmenorrhoea is often accompanied by such extragenital symp- 
toms as eye-strain and contraction of the field of vision, cutaneous eruptions, 
such as acne and eczema, and by neuralgic conditions, for example, tooth- 
ache and joint pains. 

Etiology. — Dysmenorrhea may be the result of a large number of different 
causes. It is not a disease, but a symptom, the reason for which, however, it is 
sometimes extremely difficult to find. The treatment of dysmenorrhoea should 
never be continued indefinitely without the fullest sort of an investigation 
being made to determine whether or not it is dependent upon demonstrable 
organic alteration. If this is not done, symptomatic treatment may be carried 
on for a considerable length of time without giving relief, when some simple 
operative plan might effect an immediate cure. 

The cases in which dysmenorrhoea is most likely to be looked upon as a 
disease and not as a symptom are those in which no organic lesion can be 
found to explain it, or the anatomic variation from the normal may be so slight as 
to make it doubtful whether it is really responsible for the trouble. Dysmenor- 
rhoea of this type may be ascribed to a certain degree of hypoplasia of the 
uterus or adnexa, of which little gross evidence exists. Such a con- 
dition would be difficult to demonstrate even microscopically, as it probably 
affects mostly the blood and nerve supply. 

For convenience of description and study, dysmenorrhoea may be divided 
into two classes: (i) That due to congenital defects, and (2) that due to 
acquired lesions. It is to be understood that developmental defects of the 
genital apparatus include not only those that are demonstrable, but also 
those that are of such degree as almost to deserve the name of hypothetic. 
To the latter we have given the term " vascular and nervous " for want of a 
better one; they are often associated with general hypoplasia — the subjects 
are physically subnormal and have an unstable nervous organization. 

Dysmenorrhoea Due to Development Defects. — These defects usually 
consist of abnormalities in the size and the shape of the uterus. They may 
be very well marked or only slight. The uterus may be infantile, and the 
body of the organ may be acutely anteflexed on the cervix, which is long, 
narrow, and tapering, or short and knob-like. The cervical canal itself may 

2 The belief that physiologic and pathologic states of the female generative organs 
often produce headache is widespread. Text-books list dysmenorrhoea, " uterine disease," 
disease of the ovaries and even of the bladder, as causes of headache, and yet no real 
justification for these beliefs has been attempted. Headache is, of course, exceedingly com- 
mon during menstruation, but so it is in eclampsia, and yet no one to-day connects the 
eclamptic headache in any direct way with the condition of the uterus. Toxemia of the 
menstrual period is a much more plausible, though not a demonstrable, hypothesis. — Cabot, 
R. C. : Differential Diagnosis. Saunders, Phila., igii. 



588 GYNECOLOGY 

be very narrow and stenotic, or it may be kinked and obstructed by a sharp 
anteflexion. There may be double formation (uterus didelphys or uterus 
bicornis), with equal or unequal development of the two halves; this condi- 
tion may be associated with stenosis, with retention of the menstrual fluid 
behind the point of obstruction (see Gynatresia, page 23). 

In addition to such defects, which are easily recognized, many cases of 
dysmenorrhcea are seen in which no apparent cause can be demonstrated, 
the pain being explainable only on the ground of a deficiency in the mus- 
cular tissue of the uterus or an abnormal nerve or blood supply to the uterus 
and ovaries ; or the individual may be so constituted that what would cause 
but slight discomfort in the average person would in her produce severe 
pain (psychoneurosis). 

As moderate degrees of anteflexion and stenosis may be combined with 
developmental defects in the vascular or nervous apparatus, it is often quite 
impossible in an individual case to say that the pain is or is not due entirely 
to an obstruction of the cervical canal. If the surgeon does not bear the 
possibility of this combination of causes in mind, he will often be disap- 
pointed in the results of an operation to overcome the stenosis or anteflexion. 5 

The influence of cervical stenosis as contrasted with the influence of the 
developmental deficiency of the vascular and nervous supply may be differ- 
entiated, or an attempt may be made to differentiate between the conditions 
by observing with particular care the time of appearance of the pain and 
other peculiarities. Thus, when dysmenorrhcea is due to obstruction of the 
cervical canal, it usually precedes the appearance of the menstrual flow, and 
begins to subside as soon as the flow is well established. It may recur at 
intervals even after the flow appears, but there is a tendency for the 
paroxysms of pain to become less frequent and less severe. The pain is 
situated in the lower abdomen — suprapubic ; it may be felt more on one side 
of the midline than on the other; it may radiate to the sacral region or down 
the thighs. The paroxysms of pain mark a succession of uterine contrac- 
tions that recur until additional menstrual fluid is expelled, when the pain 
subsides for a time (see Pathologic Anteflexion, page 239). 

The type of dysmenorrhoea due to nervous or vascular defects often 
begins several days before the flow sets in, and may persist throughout the 
period. Preceding the period there may be severe, dull, aching pain in the 
lower abdomen, back, and limbs, with an exaggeration of the usual nervous 
phenomena of menstruation. During the flow the pain is most severe in the 
ovarian and sacral regions ; it is described as boring or burning in nature, or 
as " great soreness," etc. The patient is often poorly developed physically 
and of a nervous temperament. 

Dysmenorrhoea due to developmental defects dates from the very onset 
of the menstrual function — the age of puberty. 

As the obstructive form of pain may be combined with the nervous or 



l3 Kelly and other observers have expressed a doubt as to whether stenosis of the cervix 
alone produces painful menstruation, basing their doubt upon the following reasons : 
First, because it is said that the pain begins when there is no blood in the uterus ; secondly, 
the amount of blood is too small ; thirdly, menstrual blood will pass through an exceedingly 
narrow lumen; and fourthly, only one-half of the cases of stenosis have dysmenorrhoea. 



DISORDERS OF MENSTRUATION 589 

vascular and nervous type, it may readily be seen that the surgeon must 
always be guarded in making a prognosis of an operation to overcome 
stenosis or obstruction of the cervical canal. 

Dysmenorrhea Due to Acquired Lesions. — Dysmenorrhoea may be a 

:z)tom of almost any pelvic disease : for example, uterine displacement. 
cervical polyp, chronic endometritis or hyperplasia of the endometrium, 
pelvic inflammatory disease, and ovarian tumors. Displacement downward 
and backward of the small anteflexed uterus is regarded by Graves as a more 
or less frequent source of dysmenorrhoea. In all these conditions the pain 
is but a symptom, and its cure lies in the correction of the lesion producing 
it. Certain changes in the ovaries that are difficult to recognize upon pelvic 
examination are believed in some cases to be responsible for dysmenorrhoea : 
these are probably predisposed to by repeated pelvic congestion, as from 
prolongd sitting, chronic constipation, and insufficient exercise. The extent 
of the influence of masturbation and ungratified sexual inclinations on their 
production is not known. The anatomic alterations consist of a thickening 
of the tunica albuginea. increased density of the ovarian stroma, and the 
immature development of numerous follicles, so that the ovary undergoes a 
form of cystic degeneration ( microcystic i . The anatomic changes in the 
ovary may be responsible for the dysmenorrhoea. and are also an evidence 
of faulty ovarian function, as well as of disturbance in the vascular and 
nervous supply of the entire pelvis. 

Acquired dysmenorrhoea assumes the aspect of a d:sr?.st r: se in those 

rs in which it cannot be explained satisfactorily by the gross local condi- 
tions found on pelvic examination. Here we again approach the vascular 
and nervous type above discussed under the developmental defects. Such 
menstrual pain may develop after puberty, and be due entirely to the influ- 
ence upon the general health of faulty hygiene, intercurrent diseases, ex- 
:essive tax upon the nervous system, and mental strain. Mental depression, 
neurasthenia, and general hyperesthesia are predisposing factors in the pro- 
duction of the painful subjective phenomena associated with menstruation 

ychoneurosis i. The same processes, occurring in vigorous, healthy in- 
dividuals, would not be regarded or appreciated as constituting actual pain. 
On the contrary, dysmenorrhoea may, in the course of time, have a marked 
effect upon the nervous equilibrium of the individual, even though she 
were previously essentially normal in this respect, and lead to nervous irri- 
tability, exhaustion, and depression. 

In the acquired forms of dysmenorrhoea the history may show that nor- 
mal and uncomplicated menstruation occurred for a longer or shorter period 
after puberty and that the dysmenorrhoea developed pari passu with the 
acquired lesion. It need not be explained, of course, that all acquired lesions 
may be engrafted upon a developmental defect existing at puberty. 

Treatment. — It is to be understood that the treatment here laid down does 
not necessarily apply to cases in which dysmenorrhoea is but a symptom of a gross 
disease of the pelvis, nor to those cases in which it is quite certain that 
marked anteflexion and stenosis of the cervix are responsible for the condi- 
tion. Under these circumstances the treatment is self-evident, and is de- 
scribed elsewhere. Onlv those cases will be dealt with here in which there 



590 GYNECOLOGY 

is no gross disease to account for the suffering, and those in which some 
doubt exists as to whether a stenosis of the cervix or an acute anteflexion 
is or is not responsible for the pain. 

Every patient should at the outset be examined most carefully with regard 
to her general condition, physical and mental, and suitable measures pre- 
scribed to place her in good condition. The anaemic, constipated, over- 
worked girl of sedentary occupation should be instructed in regard to the 
care of the bowels, the taking of regular exercise in the open air, the selec- 
tion of food, and the habit in dress (see Hygiene of Adolescence, p. 609). 
An effort should be made to remove any source of mental anxiety and worry, 
or so to encourage and fortify the patient by suggestion that she will be 
able to overcome any mental distress. These conditions may be difficult to 
correct, but an earnest effort should, nevertheless, be made to do so. 

At the time of the menstrual period the bowels should be moved freery 
with the aid of salines. Hot sitz-baths, hot rectal injections, or the applica^ 
tion of an ice-bag to the sacrum may give relief from the pain. The 
remedies that have been recommended and prescribed are almost number- 
less, and in many cases useless. Of the simpler drugs most likely to prove 
effectual may be mentioned aspirin and the bromides. In many cases of 
the congestive type, as well as in some of the obstructive form, considerable 
relief has been gained from the administration of ovarian substance or ex- 
tract of the corpus luteum of the cow and sow. Failure in the use of these 
remedies may be due to insufficient dose. 

In some cases of the obstructive type with paroxysms of uterine colic the 
administration of atropin sulphate in doses of 1/100 grain three to six times 
a day for several days preceding the onset of the period has been followed by 
relief. Atropin has been advantageously combined with aspirin. 

The most recent addition to the therapeutics of dysmenorrhoea is benzyl 
benzoate. It is said to have a selective anti-spasmodic effect on smooth 
muscle-fibers. It is recommended chiefly in that form of dysmenorrhoea, 
designated as vagotonic by Block, which is marked by spasm and increased 
irritability of the uterine muscle. Any form, however, may be benefited. 
The drug is exhibited in a 20 per cent, emulsion, one to two drams at a dose. 
There is also a hypodermic preparation on the market. 

The nasal treatment of dysmenorrhoea, first advised by Fliess, has been 
favorably reported on by a number of reliable observers. Fliess discovered 
that if the areas on the anterior half of the lower turbinate bones and the 
tuberculum of the septum, which may be found to be congested during the 
menses, were cocainized, menstrua, pain was relieved. In the beginning of 
the treatment cocaine may be used as a test to indicate whether success is 
likely to follow. To secure a permanent effect, cauterization with trichlor- 
acetic acid or the cautery, preferably the former, may be carried out be- 
tween the periods — about four times during the interval. It may be desir- 
able to repeat the treatment -at intervals over a period of two months. To 
this end the patient should be placed in the hands of a skilled rhinologist- 
(For the technic of this treatment the reader is referred to the paper of 
Brettauer; see bibliography at end of chapter.) 

Often none of these measures will be effectual, and relief from medicines can 



DISORDERS OF MENSTRUATION 591 

be obtained only by using a derivative of opium in combination with a coal-tar 
preparation. A favorite prescription is a capsule containing codein (y 3 grain) 
and compound acetanilide powder (5 grains). These should be used very spar- 
ingly, however, and the patient should be made aware of what she is taking. 
The minimum amount— no more — that will control or render the pain bear- 
able should be taken. One or two capsules at a period will tide the patient 
over the worst of her suffering. If more are required, the case should be 
treated surgically. 

Stimulation of the uterine muscles and development of the canal of the 
cervix by the application of the intrauterine galvanic electrode have brought 
a certain measure of relief in some cases. This form of treatment is gen- 
erally objectionable, however; when it succeeds in dysmenorrhcea of the 
obstructive type, the dilatation of the canal incident to the treatment is pos- 
sibly largely responsible for the results. When other measures, drugs, and 
operation fail, galvanism may be tried. In at least one case this form of 
treatment successfully relieved violent menstrual pain in the sacral region 
and thighs after dilatation of the cervix, cocainization of the nasal septum, 
and numerous drugs had been used without result. 

When a sufficient time has been allowed to elapse for improvement in the 
general conditions to exert an influence on the menstrual periods, and if no 
relief has been obtained as the result of the methods here described, oper- 
ative measures must be considered. The simplest and most effectual con- 
sists of dilatation of the cervical canal under anaesthesia, followed by the 
introduction of an intrauterine stem, that of Norris being preferred. When 
the pain is due solely to obstruction of the cervical canal, such a procedure 
will favorably influence the discomfort, and may result in a complete and 
permanent cure ; even when the pain is due, at least in part, to faulty vascular 
or nervous development, improvement may follow the adoption of this plan. 
(For the technic of this procedure see page 243.) The effect of the drain 
is not only to overcome the stenosis or kinking of the cervical canal, but 
also to increase the nutrition of the part and improve its vascular supply. 

When this plan is not followed by success, the surgeon will do well to 
hesitate before suggesting further operative interference. At times the 
suffering is so great that other measures must be considered. Thus, if the 
cervix is very acutely anteflexed and the anterior vaginal wall is short, 
Reynolds' plan of separating the cervix from its anterior vaginal attach- 
ment by a transverse incision, followed by longitudinal suture, may be 
adopted, or Pozzi's or Dudley's operation may be used, either alone or com- 
bined with the introduction of a Norris drain. 

In very severe cases, in which there is probable or undoubted ovarian 
enlargement, an exploratory laparotomy for the purpose of ascertaining the 
condition of the ovaries is justifiable. Unless the ovary is positively and un- 
mistakably diseased, its removal usually has but little influence on the con- 
dition. In some cases, where the ovarian capsule is thickened and the ovary 
is filled with small, unruptured Graafian follicles, an attempt has often been 
made to relieve the pain by resecting a portion of the ovary or removing it 
entirely. This plan has frequently been followed by failure, and occasionally 



592 GYNECOLOGY 

the condition of the ovaries and of the patient has been rendered worse 
than before. 

If, therefore, the ovary is not distinctly diseased, it is best to allow it to 
remain, suspending it if prolapsed, or freeing it, if adherent. The veins of 
the broad ligaments should be carefully examined, and if they are varicose, 
a portion of them should be excised. In a majority of instances it is advis- 
able to avoid any operative treatment except that directed to the cervix. In 
many cases nothing short of pregnancy and labor will cure the patient, so 
that the most the physician can do after the simpler operative plans have 
failed is to tide her along as best he can. It is exceptional to find a case in 
which general measures or operation on the cervix do not at least greatly 
relieve, if not cure, the patient. In the exceptional cases the best that can 
be done is to prescribe suitable medicinal treatment, and to observe the 
pelvis closely, so that any diseases may be detected early in their develop- 
ment. It has been said that in very rare instances supravaginal hyster- 
ectomy with bilateral salpingo-oophorectomy is justifiable in order to cure 
an otherwise hopeless case. 

INTERVAL DYSMENORRHEA 

Attacks of pain resembling dysmenorrhcea may recur periodically (half- 
way or thereabouts) between the menstrual periods (interval pain). This 
has been said to be due to aberrant ovulation occurring in chronically dis- 
eased ovaries. In many of these cases, however, ovarian disease cannot 
be demonstrated. 4 

MEMBRANOUS DYSMENORRHCEA 

A severe, cramp-like, paroxysmal pain accompanying the menstrual flow is 
sometimes associated with a discharge from the uterus of portions of the uterine 
mucosa; occasionally a considerable portion of the endometrium w T ill be dis- 
charged in one piece. Under such circumstances the discharged tissue with the 
attached blood-clot presents the appearance of a more or less perfect cast of the 

4 Heaney, in a paper upon Periodic Intermenstrual Pain, gives a review of 66 cases. 
3 of which he observed personally. The frequency of the condition is given by Rosner as 
12 in 2350. The majority of the cases occurred between the ages of twenty-five and thirty- 
five. The frequency in patients above and below these ages was about the same. The largest 
number of cases seemed to correspond to the period of greatest sexual activity. 

There was a high percentage of sterility — about 33 per cent. The menstrual type in 
the cases varied. Almost all the patients were regular as regards their periods, but there 
were quite a number in whom the iow was scanty. In a few intermenstrual pain 1 began 
at puberty. In most of the others it occurred quite a number of years afterward. The 
pain is somewhat characteristic. It starts at any time midway between the menstrual 
periods, on or about the fourteenth day after the onset of the last menstruation. The pain 
is distinctly periodic, and occurs every month with as much regularity as menstruation 
itself. When once established, it rarely fails to appear unless amenorrhcea occurs, when 
as a rule, it ceases. 

The pain usually begins on one side of the lower abdomen or groin, the left more 
often than the right ; it is cramp-like, spasmodic, and intermittent, with periods of relative 
or complete recession. Radiation to the leg, to the opposite side, or occasionally to the 
groin is noted. The pains become more frequent and of longer duration, and generally 
become diffused over the entire lower abdomen, with tenderness on pressure. Rarely the 
pain is dull and aching ; more often it is sharp, tearing and lancinating in character. In 
the milder cases the suffering is relieved by the application of heat; in severe cases opiates 
are necessary. The duration is usually two or three days; it may, however, continue 
until near the next menstrual period. The time of greatest relief is usually just after 






DISORDERS OF MENSTRUATION 593 

uterine cavity. The diagnosis can be arrived at only by making a microscopic ex- 
amination of the discharged tissue, since there is difficulty in distinguishing 
macroscopically between endometrial tissue and clotted blood. 

Etiology. — The cause of membranous dysmenorrhcea is not known abso- 
lutely. Three factors have been held responsible : First, an interstitial endo- 
metritis that interferes with the separation and expulsion of the endometrium in 
fragments (Winter ascribes the pain to the exudation previous to the detach- 
ment of the membrane, and not alone to uterine contraction) ; secondly, a 
diminution in the tryptic ferment of the uterine mucosa, which normally 
softens and digests the mucosa preparatory to its extrusion; and thirdly, some 
as yet unexplained reaction in the endometrium resulting from a reduction 
in the ovarian hormones. 

Some authorities have denied the possibility of an inflammatory disease 
of the endometrium serving as the cause of membranous dysmenorrhcea, on 
the ground that the condition often occurs in virgins and in sterile but 
otherwise healthy women. Others believe that the inflammatory lesion may 
have dated from infantile gonorrhoea ; or that the endometrial change may 
be the late result of an acute exanthematous disease in childhood. In these 
cases the menses are often irregular and sterility is the rule. When preg- 
nancy does occur, it is frequently interrupted. 

Treatment. — The condition is difficult to overcome ; before resorting to oper- 
ative measures, the various anti-dysmenorrhceic drugs and ovarian substance 
should be used. The operative treatment consists in dilating the cervix, curette- 
ment, and the introduction of an intrauterine stem. In the most severe cases 
supravaginal hysterectomy with conservation of the adnexa may ultimately 
be required. 

THE MENOPAUSE 

The menopause, or the cessation of the menstrual function, marks the 
end of the reproductive period of a woman's life. As a rule, the menopause 
occurs at about the age of forty-five, although it may take place at any time 
between the fortieth and the fiftieth year. It is frequently the case that 

menstruation. Purefoy mentions a case in which the patient had intermenstrual pain in 
the breasts and none in the abdomen. At times the pain is accompanied by a colorless 
vaginal discharge. 

All cases show pathologic alterations, and the author states that it has been difficult 
to separate the essential from the complicating lesions. Out of 29 cases which the author 
collected from the literature, laparotomy is recorded as having been performed in 6; in 
5 a fibroid uterus was found, and in all the ovaries were either sclerotic or had undergone 
cystic degeneration. Rosner, in a series of 12 private patients, found only one with normal 
pelvic organs ; the others showed increased sensitiveness or enlargement of the ovary or 
ovarian prolapse. There was also a general increase in the uterine dimensions which he 
called " diffuse pathologic hypertrophy." 

Various theories have been adduced to explain intermenstrual pain. Drennan believes 
the pain to be due to the escape of a non-fertilized ovum, associated with expulsive efforts 
on the part of the uterus. Addinsell ascribed the symptom to hydrops tubes proiluens, the 
pain being thought to occur when the tube expels its contents. Kiistner asserts that the dis- 
turbance is the result of ovulation which is asynchronous with menstruation, and that the 
pain is due to the resistance met by the follicle in its effort to burst and release the ovum. 

After discussing these theories and others that have been proposed, as well as the 
relation between menstruation and ovulation, the author states that he believes that periodic 
intermenstrual pain is an insufficient or abortive attempt at menstruation, the pain being 
a form of dysmenorrhcea, the whole picture depending upon degenerative and sclerotic con- 
ditions in the ovaries and uterus. 
38 



594 GYNECOLOGY 

when menstruation begins early in life, it ends late, and that when • it 
begins late, it ends early. 

Symptoms. — The menstrual flow, as a rule, does not cease at once, 
but the menstrual periods become gradually less frequent and the flow 
less profuse, finally disappearing altogether. During the time the menstrual 
function is disappearing certain subjective symptoms appear that may be 
regarded as evidence of the alterations in metabolism that necessarily take 
place upon the abrogation of such intricate processes as ovulation and 
menstruation. The woman experiences general or local sensations of heat or cold, 
attacks of profuse perspiration, nervousness, and irritability, headache, and 
depression of spirits. In the healthy, robust woman, such symptoms may be 
disregarded ; but in the neurotic and weak they may be bitterly complained 
of and associated with mental irregularities. 

Treatment. — For healthy women no especial management is necessary dur- 
ing the time of the menopause. When the nervous manifestations are marked, 
and when they cause considerable distress, it is advisable to put the patient in 
as good general condition as possible, to tone up the nervous system, and to 
employ ovarian or corpus luteum extract and nerve sedatives, such as 
sumbul, viburnum, and the bromides. The rest cure is sometimes of benefit. 

The most important part of the management of the menopause is to be 
constantly on guard lest early symptoms of beginning malignant disorders 
are overlooked. For this reason any woman coming under the care of a 
physician at this period of her life should be questioned regarding leucor- 
rhoeal discharge, irregular bleeding, and local symptoms of any sort refer- 
able to the pelvic organs. Unless the patient is absolutely free from abnor- 
mal symptoms of any kind, a thorough examination should be made. It 
need not be stated that the indication for this examination is all the more 
urgent when the amount of blood lost at a period increases or when bleed- 
ing occurs between the periods or long after the menopause is believed to 
have been past. 

There is a very deeply rooted impression that any menstrual irregularity 
at the time of the menopause is more or less peculiar to that time of life 
and entirety within the bounds of health. This is a fallacy. In normal 
women the menstrual epochs become more and more infrequent, and with 
each period the flow grows less. Although a deviation from the normal does 
not, by any means, always indicate malignancy, it occasionally does so, 
and has often been disregarded until the patient's condition is hopeless. 
For that reason patients at the menopause should be questioned regarding 
their menstruation, and if there is any irregularity or variation from the 
normal, a thorough examination should be undertaken immediately, so as 
to exclude diseases of a malignant type. Women should be acquainted of 
these facts by their family physician, so that they will voluntarily seek his 
advice immediately upon the appearance of pelvic symptoms. 

PREMATURE MENOPAUSE 

Etiology.— The menopause may occur considerably earlier in life 
than normal. Not infrequently it takes place during the early thirties, 
and is often accompanied or preceded by a considerable increase of adi- 



DISORDERS OF MENSTRUATION 595 

pose tissue throughout the body. Such women have usually had a late 
puberty, are short in stature, suffer from amenorrhcea, dysmenorrhcea, and 
sterility, and give the general impression of incomplete sexual development. 
There may be some pernicious influence of the thyroid gland to explain the 
cessation of ovarian activity. Amenorrhcea and obesity are observed in 
hypothyroidism. The pituitary gland may also be concerned in the prema- 
ture menopause — hypofunction of the gland has been found clinically to be 
associated with irregular menses, amenorrhcea, and sterility. Similarly the 
adrenal glands, when defective, may be associated with diminished func- 
tion and even with atrophy of the genitalia. In a few cases acquired changes 
in the ovary (oophoritis associated with acute febrile diseases, lactation, 
atrophy, etc.) are probably the important factors. 

Treatment. — The treatment is very unsatisfactory and often of no avail. An 
attempt may be made to secure results by treating the adiposity, the reduction of 
which, in some cases at least, may have a beneficent effect on the menstrual 
periods. In addition, thyroid, pituitary, adrenal, and ovarian extracts, 
tonics, and various emmenagogues may be prescribed. Finally, the cervix 
may be dilated and a Norris stem introduced, in the hope that the nutrition 
of the uterus may be improved and a return of the menstrual flow 
thus secured. 

ARTIFICIAL MENOPAUSE 

Etiology. — The artificial menopause is the abrupt cessation of the 
menstrual function occasioned by the removal of both ovaries during the 
course of a pelvic operation. In women past thirty this artificial meno- 
pause may be accompanied by no more serious symptoms than those that 
attend the normal menopause. In highly neurotic women of this age, or in 
women under twenty, however, the condition may be accompanied with the 
most exaggerated nervous symptoms and complaints. In mentally weak 
individuals a form of mental perversion may develop, the patient continu- 
ally indulging in morbid introspection, and in severe cases becoming 
mentally deranged. 

In adolescence ovariectomy is a serious matter, sometimes changing the 
entire life of the individual, rendering her prematurely old, and being con- 
ducive to general ill health and many forms of nervous disorders. There 
may be a tendency to obesity and an overgrowth of hair upon the face. 
Such women are said to show a tendency to approach the male type and to 
lose sexual feeling. Castration before marriage interferes with the develop- 
ment of a libido sexualis. In women who have been married for some time 
and in whom the libido sexualis is matured, there is usually no diminution 
of sexual feeling. Indeed, the removal of diseased and painful ovaries may 
make coitus more agreeable or at least less objectionable. To every woman 
the knowledge that she is incapacitated for motherhood brings a certain 
measure of regret, determined by the intensity of her feelings. To avoid 
such distressing sequelae removal of both ovaries is to be most scrupulously 
avoided up to the age of thirty-five. 

Some gynecologists, notably Graves, believe that the artificial meno- 
pause in itself causes no more marked disturbances than does the normal 



596 GYNECOLOGY 

change of life. He divides the nervous symptoms of the menopause into two 
distinct groups — the vasomotor and the neurotic. The first are due to the 
loss of the ovarian secretion, and last, on the average, from two to three 
months ; they are almost invariably relieved by the exhibition of ovarian 
extract. The second group, the psychoneuroses, he believes are by no 
means " definitely consequent " on the loss of the ovaries. They may be 
brought about by carelessly performed operations that leave the patient 
with distressing post-operative sequelae, such as adhesions, painful stumps, 
prolapse of the cervix, incisional hernia, etc., or by mental suggestion — a 
sense of degradation induced by the criticism of an unfeeling husband or the 
remarks of unwise friends. 

Treatment. — The treatment of the artificial menopause is unnecessary, of 
course, in women in whom the symptoms are not distressing. In others the dis- 
agreeable nervous symptoms may be relieved by the administration of the desic- 
cated entire ovary or the desiccated corpus luteum, attempting to supply in 
this way what is believed to be the internal secreting structure of the ovary. 
The most satisfactory preparation is the freshly desiccated entire ovary. 
This may be given in tablet form, 2 to 5 grains three times daily. The 
extract of the corpus luteum is preferred by some, and in many cases has 
undoubtedly given excellent results ; the dose is 5 grains three times daily. 
A fluid preparation of the extract of corpus luteum for hypodermic use is on 
the market. As with all organic extracts, the initial dose should be small 
and gradually increased, if necessary. Nerve sedatives, such as the bromides, 
viburnum-opulum, sumbul, and asafetida, at times do good. Abundant 
exercise or an active out-of-door life is of the greatest benefit. An effort 
should be made to minimize the importance of the symptoms, and the 
patient should be encouraged to take a matter-of-fact view of her condition. 
Many foolish notions and depressing beliefs relative to castration may be in 
the patient's mind. 

BIBLIOGRx\PHY 

Bab. H. : " Organotherapeutische Erfahrungen und Andwendung von Aphrodisiaka in der 
Gynakologie." Frauenarzt, 1913, xxviii, 543. 

Brettauer, J. : " Further Report of Cases of Dysmenorrhea Relieved by Nasal Treatment." 
Trans. Am. Gyn. Soc., 1913, xxxviii, 80. 

Busey, S.C. : "Vulvar or Vaginal Hemorrage in the Newly-born." Trans. Obst. and Gyn. 
Soc, Wash., D. C. 1889-90, iii, 25. 

Cabot, R. C. ; Differential Diagnosis. Saunders, Phila., 1911. 

Coe, H. C. : "Menstrual Disorders of Obscure Origin.'' Am. Jour. Obst., 191 1, lxiii, 790. 

Dickinson, R. L. : " Conservation of Sound Ovaries and Tubes in Hysterectomies Near 
the Menopause, Except in Malignant Disease." Trans. Am. Gyn. Soc, 191 1, xxxvi, 324. 

Ehrenfest, H. : " The Influence of the Central Nervous System in the Causation of Uterine 
Hemorrhage." Am. Jour. Obst., 1908, lvii, 161. 

Fliess : " Die Nasale Reflexneurose." Verhandl. Cong, f . innere Med., Zwolfter Congress, 
S. 384, Wiesbaden ; Ibid. : " Magenschmerz u. Dysmenorrhea in neuen Zusammen- 
hang." Wien. klin. Rundschau. 1895, ix, 1. 

Fr.enkel, L. : " Normale u. Pathologische sexual Physiologie des Wiebes." Handbuch der 
gesammten Frauenheilkunde, W. Liepmann, ii, Vogel, Leipzig, 1914. 

Frank, R. T. : " The Clinical Manifestations of Disease of the Glands of Internal Secre- 
tion in Gynecological and Obstetrical Patients." Surg., Gynec. and Obst., 1914, xix, 618. 

Frankl, O. : " Pathologische Anatomie u. Histologic der weiblichen Genitalorgane." Hand- 
buch der gesammten Frauenheilkunde, W. Liepmann, iii, Vogel, Leipzig, 1914. 

Franoue, V.: " Beitrage zur pathologische Anatomie der Endometritis Exfoliativa." 
Ztschr, f. Geburtsch u. Gynak., 1891, xxii, 1. 



DISORDERS OF MENSTRUATION 597 

Graves, W. P. : " Influence of the Ovary as an Organ of Internal Secretion.'" Am. Jour. 

Obst., 1913, lxvii, 649: Ibid.: "Ovarian Organotherapy." Trans. O.. G. and A. S.. 

A. M. A., 1917, 147. 
Heaney, N. S. : " Periodic Intermenstrual Pain." Surg., Gyn. and Obst., 1910, xi, 361. 
Kelly, H. A. : " Dysmenorrhcea — Its Causes and Treatment." Am. Jour. Obst., 1894, 

xxix. 502. 
Litzenberg, J. C. : " The Use of Benzyl Benzoate in Dysmenorrhcea." Jour. Am. Med. 

Asso., 1919, lxxiii, 601. 
McRae, F. W. : " Conservative Surgery of the Pelvic Organs and the Lower Abdominal 

Wall." Jour. Am. Med. Asso., 1910. lvii, 2215. 
Montgomery, E. E. : "Premature Menopause." Med. News, 1894, lxv, 461. • 
Noble, C. P. : " Profuse Menstruation." Ann. f. Gyn. et Pediat., 1894, vii, 334. 
Norris, C. C. : " The Menopause." Am. Jour. Obst., 1910, lxi, 203. 
Novak, E. : " Some Neglected Principles in the Causation of Menstrual Disorders." Am. 

Jour. Obst., 1910, lxii, 601 ; Ibid. : " The Atropin Treatment of Dysmenorrhcea." Jour. 

Am. Med. Asso., 1915, lxiv, 120: Ibid. : "The Corpus Luteum." Trans. O., G. and 

A. S.. A. M. A., 1916, 44; Ibid. : "The Pathologic Physiology of Uterine Bleeding." 

Trans. Sect. O., G. and A. S., A. M. A., 1914, 220. 
Ploss : Das Weib in der Natur u. Volkerkunde. Leipzig, 1905. 
Saxes, K. I. : " Is Membranous Dysmenorrhcea Caused by Endometritis? " Trans. Sect. O., 

G. and A. S.. A. M. A., 1913, 304. 
Stephenson : " On the Relation Between Chlorosis and Menstruation, an Analysis of 252 

Cases." Trans. Obst. Soc, London, 1889, xxxi, 104. 
Stieda : " Chiorose u. Entwickelungstorungen." Ztschr. f . Geburtsch. u. Gynak., xxxii, 60 

and 97. 
Tait, L. : Diseases of Women and Abdominal Surgery. Phila., 18S9. 
Thorn : " Beitrage z. Lehre von der Atrophia Uteri." Ztschr. f. Geburtsch. u. Gynak., 

xvi, 57- 
Virchow : " liber die Chiorose u. die damit zusammenhangenden Anomalien im Gefassap- 

parate." Beitrage f. Geburtsch. u. Gynak., 1898, i. 
Wood, H. C. : Therapeutics. Lippincott, Phila., 1907. 



CHAPTER XXXIII 
STERILITY 

A woman may be said to be sterile when conception does not occur 
within several years of marriage. The truth of this statement rests upon 
the fact that no measures have been taken to prevent impregnation and that 
the male is healthy. Sterility may be either relative or absolute. Relative 
sterility is comparative sterility ; that is, a woman may bear a child within 
a short time of marriage and none after that. This is frequently spoken of 
as one-child sterility, and is usually dependent upon an accident or a com- 
plication attending the first labor, which prevents another conception from 




v&rcvvrvoA 



FlG. 461. — Schematic outline of generative tract showing: Escape of ovum; 
penetration of spermatic particles; fertilization of egg. 

taking place. Before declaring that a woman is sterile one must be certain 
that all the conditions favorable to conception exist in the interested person 
of the opposite sex. 

Etiology. — The causes of sterility are numerous, and include all the con- 
ditions that may interfere in any way with the physiology of normal im- 
pregnation. Conception takes place usually in the outer third of the tube ; 
the spermatic particles by their own motility penetrate to this point, and 
there lie in wait for the ovum, which is discharged by the Graafian follicle, 
is caught up by the fimbria, and is carried down into the tube (Fig. 461). 
After impregnation the ovum passes slowly through the tube into the uterus ; 
598 



STERILITY 



599 



a period of from five to seven days is believed to be consumed in its passage. 



In the meantime the uterine mucosa has undergone certain 



changes in 




preparation for the reception and nourishment of the gravid ovum. A more 
detailed description of this process can be found on page 71. 

Granting that the masculine function is perfect, sterility on the part of 
the female may be dependent upon imperfect development or disease of any 
part of the genital tract that: (1) Prevents ovulation or produces unhealthy 
ova; (2) renders the sexual act incomplete or imperfect; (3) prevents the 
spermatic particles and the ovum from meeting ; or (4) favors the destruc- 
tion of the ovum after it 
has become impregnated. 
Polak declares that there is 
a definite chemico-physio- 
logic factor in conception 
that is at present unexplain- 
able which is a cause of 
sterility. 

Imperfect Development. 1 
— The ovary may be small 
and the ova few and imper- 
fectly developed. This is 
usually a part of a general 
hypoplasia especially 
marked in the generative 
organs, and may be the re- 
sult of ancestral syphilis, 
alcoholism, or epilepsy. 
Other causes of deficient 
ovulation are wasting dis- 
eases, hypophyseal and D 
other internal glandular 
dyscrasias, chronic poison- 
ing, as by lead, etc., con- 

, " FlG. 4 62 - — Semi-diagrammatic outline of uterus showing various 

I he Capsule Of the OVarv causes of sterility: (A) infantile type of uterus, cervix long and ste- 

, t1 , \ notic with acute anteflexion causing obstruction; (B) submucous 

may be UnUSUallv tOUgh and myoma causing obstruction or interference with nidation; (C) inter- 

1 1 ,\ r+ n stitial myoma causing obstruction or interference with nidation. 

dense, and the Graafian 

follicles, after attaining a certain size, may undergo regression and partial 
absorption — ovulation does not occur. Ovulation may be prevented by 
cystic degeneration of the ovary or by a persistent corpus luteum. 

The Fallopian tubes may be of the fcetal type ; that is to say, they may be 
very long and greatly twisted, so that the impregnated ovum must travel 
a considerable distance before it reaches the uterus ; hence it may perish on 
the way, or the tube may present diverticula in which the impregnated ovum 

1 For a complete list of the developmental defects of the genitalia, any of which, 
under certain circumstances, may be the cause of sterility, see the section on Malforma- 
tions^ Only the abnormalities most frequently associated with sterility as seen in 
practice will be discussed here. 





600 



GYNECOLOGY 



is caught, or there may be constriction of the tube or poorly developed 
fimbriae, or the musculature may be ill developed and peristalsis weak. The 
uterus may be of an infantile or foetal type, so that proper embedment and 
nourishment of the ovum cannot be provided by the small, fibrous organ, 
with its attenuated and poorly vascularized endometrium. The cervical 
canal may be stenotic, so that the spermatic particles are prevented from 
entering the uterus. The cervix may be so elongated and sharply anteflexed 
that the seminal fluid does not bathe the external os (Fig. 462, a), and the 
vaginal fornix may be so shallow that the seminal fluid runs out of the 
vagina soon after coitus (Fig. 463, b). The vagina and vulva may be so 
greatly distorted as the result of malformation as to constitute a more or 
less complete barrier to copulation. 

Acquired Diseases. — Acquired diseases that produce sterility are chiefly 
inflammatory in nature. 2 Such diseases close the abdominal ostia of the 
tubes by reason of adhesions (Fig. 464, c), obstruct the lumen of the tubes 




Fig. 463. — Semi-diagrammatic outline of uterus showing various causes of sterility: (/I) Sal- 
pingitis or adenomyoma of interstitial portion of tube acting as an obstruction to the sperma- 
tozoa; {B) cervico- vaginal junction with shallow fornices allowing semen to escape. 

by chronic inflammatory changes in the mucosa (Fig. 463, a), cause destruc- 
tion of the ciliated epithelium; produce infiltration of the tube wall, and 
angulation, so that the sperm and the ovum cannot meet. 

Such diseases also, by producing ovarian adhesions or a thickening of 
the ovarian capsule and internal circulatory changes in the ovary, may end 
in a premature atrophy of the Graafian follicles or interfere with the rupture 
of the follicle and the liberation of the ova (Figs. 464, a and b). 3 Endo- 

2 According to Lier and Asher, the woman is responsible in 60 per cent, of sterile 
marriages and the man in 40 per cent. ; and 33 per cent, of sterility in women is due to 
gonococcal infection. 

3 Reynolds describes the ovaries of fertile and those of sterile women as follows : 
" The ovaries of a fertile woman are, then, characteristically organs of uniform outline 
which show not more than one thin-walled and projecting follicle or corpus. They 
have throughout a characteristic soft and elastic feel when taken between the fingers, 
except when a single mature follicle or active corpus distends one portion of an ovary 
and yields its characteristic tactile sensation at the point. 

" In contrast, the ovaries of sterile women usually show on gross examination the 
presence of numerous thin-walled projecting follicles, or of numerous small, imperfect- 
looking corpora, or both. They are of lobulated outline, and on tactile examination 
between the fingers are tense and resistant in feel over the whole or at all events the 
greater part of the organ." 



STERILITY 



601 




<65y 



metritis, cervicitis, or vaginitis may prevent conception by generating a 
discharge that destroys or weakens the spermatic particle or the ovum or 
renders the decidua unhealthy. The normal uterine secretion is alkaline, 
which quality favors the activity of the spermatic particles — there is a cer- 
tain attraction between the plug of alkaline cervical mucus and the sper- 
matozoa. Excessive secretion or a purulent or muco-purulent secretion is 
inimical to the sperm. Excessive acidity of the vaginal secretion may prevent 
conception. Abnormal bacterial flora in the vagina may destroy or render 

less active spermatic particles deposited in the 
vaginal canal. 

Fibroid tumors, endometrial polyps, and retro- 
flexion of the uterus may, by mechanical obstruc- 
tion to the ingress of the spermatozoa, either hinder 
the occurrence of conception or be inimical to the 
development of the ovum after it has been impreg- 
nated (Figs. 462, A and B) . Such lesions prevent 
the union of the sexual elements, or if conception 
occurs, they retard the ovum's descent into the 
uterus, so that it perishes on the way, or render 
the development of the decidua so abnormal that 
the ovum is not properly embedded or nourished in 
the uterus and is soon cast off. 

Functional Defects. — Functional defects may 
play an important role in the production of sterility. 
In order for the coitus to be fruitful it is not neces- 
sary that a woman have a keen sexual feeling or 
that she experience an orgasm, although both favor 
the occurrence of conception. The spermatic par- 
ticles, if deposited at the vaginal orifice, are capable, 
by their own motility, of reaching the interior of 
the uterus and the tubes, but the completely con- 
summated sexual act favors their penetration and 
increases their number. Painful contraction of the 
vagina (vaginismus) may be responsible for 
C ^lu&y sterility. Forcible penetration in early married 

Fig. 464.— (A) Atrophicovary.no ,.- - . , , . . , . 

ova produced; (B) thickened cap- lite may result in a hyperesthesia of the external 
rupt-u?ITf° P foSicie S aS" escaped genitalia sufficiently marked to render complete 

ovum; (O abdominal ostia of tube ~ r .;+ 1 . 10 I'mr^cciKI a 
closed preventing ovum from COltUS impOSSlDie. 

entering tube. Diagnosis.— The cause of sterility in a given case 

may be difficult and often impossible to determine. Some of the anatomic causes 
may be of such a minor degree as to render them unrecognizable. Careful obser- 
vation and study of the spermatic fluid and of its behavior after it is deposited in 
the genital canal will often throw much light on the subject. 

Huhner points out that the male should first be examined as to his ability 
to provide active spermatozoa. This test, as usually carried out, consists in 
making an examination of the semen obtained in a condom as soon as pos- 
sible after coitus. There are several reasons why the mere finding of live 
spermatozoa in the fluid is not sufficient evidence to prove that the male 




602 



GYNECOLOGY 



element is satisfactory. Hypospadias or epispadias may be present, and, as 
a consequence, live spermatozoa may be recovered from a condom when, 
in the normal act, they would not reach the cervix. So, too, if emission is 
premature, semen that might never have entered even the vaginal tract 
will be found in the condom. Similarly in some cases of stricture of the 
urethra live spermatozoa may be found in semen that has dribbled through 
the stricture and been retained in the cover after withdrawal of the penis. 
For these reasons Huhner proposed to examine the vaginal, cervical, and 
uterine (fundus) secretions at varying periods of time after coitus, with a 
view to determining the presence of spermatozoa and their condition. For 
this purpose he uses a small syringe and a cannula resembling a Eustachian 
tube catheter. 

The fundus should not be examined for a day or two after coitus, for 
the finding of live spermatozoa in the fundus soon after copulation may 
lead to the supposition that the spermatozoa may have been pushed in 

ahead of the examining instru- 
ment or may have adhered to it 
upon its withdrawal through the 
cervix. The examination of the 
fundus should, therefore, be de- 
layed until a day or two following 
coitus ; the finding of live sper- 
matozoa at this time will serve to 
rule out any abnormal flexion or 
stenosis of the cervix as a cause 
of the sterility. 

The spermatozoa deposited 
upon the vulva die quickly — those 
in the vagina within a few hours ; 
within the cervical canal they live 
for a longer period and in the in- 

-Sterilitv produced through gonorrhoea causing , _„• £ -t-U^. 4-~ ,,o +V.^ *^-,^ U fl 

pyosalpinx, perioophoritis and pelvic adhesions. leriOr OI ine UterUS iney may DC 

found alive after several days. 

In conducting a test, the wife presents herself for examination within an 
hour of coitus ; if live normal spermatozoa are found in the vaginal vault or 
the cervical canal, the husband is absolved from blame. If dead spermatozoa 
are found, a condom specimen should be obtained in order to ascertain 
whether the spermatozoa were dead when ejaculation took place, or whether 
they were destroyed later by the vaginal or cervical secretions. Ultzmann 
has pointed out that the spermatozoa that are dead when ejaculated have 
their tails curled up, whereas in those that die later the tails are straight. 
If live spermatozoa are found in the cervix, but not beyond an angle in the 
canal, this flexion must be regarded as the obstacle which prevents 
their penetration. 

If live spermatozoa are found in the fundus, the sterility may be due to 
defects in the development of the uterus, such as infantilism, or to a patho- 
logic condition of the adnexa. Should measurements of the uterus by the 
sound and specula and bimanual examination show no uterine maldevelop- 
ment, and if no pathologic condition of the adnexa is demonstrated on 




Vy.S 



Fig. 46; 



STERILITY 603 

bimanual examination, then a stenosis or a kinking of the tubes may be 
present or some ovarian condition may be responsible for the sterility. 
Should live spermatozoa be found in the cervix and dead spermatozoa be 
discovered in the fundus, it is to be assumed that the endometrial secretion 
of the uterine interior is inimical to the spermatozoa. 

Hiihner's method eliminates almost entirely the necessity for question- 
ing the male, although in doubtful cases he should be subjected to a careful 
examination for signs of disease of the genito-urinary tract. 

To this work of Hiihner's may be added the important observations of 
Reynolds on the spermatic particles. If these are examined upon the warm 
stage of the microscope, either from a condom specimen or one taken 
from the vaginal vault after coitus, five types of spermatic particles may be 
distinguished: (i) The spermatozoon swims in a straight line and pref- 
erably against a current ; the end of the tail lashes from side to side so 
rapidly that it is impossible to follow its movements ; this is the first phase 
in the life of normal ejaculated spermatozoa, and may be called the 
" progressive vibratile." 5 

(2) The spermatozoon swims with much reduced speed ; the tail move- 
ment is a long, slow stroke from side to side ; the head and middle piece 
sway ; the outline is of an S shape ; the purpose of movement is direction 
more than speed; the spermatozoa seem, by a sort of tactile reaction, to 
avoid objects in the medium ; this stage is the " undulatory tactile." 

(3) The spermatozoon shows a tendency to push itself against or into 
any small masses of cells, bunting itself into any small cavity, and maintain- 
ing a slight burrowing motion effected by a lashing tail movement, not un- 
like the movements of the caudal fin of a fish. From time to time the 
organisms back out of the cavity and seek another mooring place. That is 
the " stationary bunting " phase. 

(4) The spermatozoon moves forward with a spiral, screw-like process ; 
it progresses with fair rapidity, but the swimming appears awkward and it 
is easily recognized. This is the " rotary swimming " phase. 

(5) The spermatozoon makes progress very slowly; the middle and 
upper portions of the tail lose their flexibility and balance to a considerable 
degree, and the lower tail motion swings the forward part of the sper- 
matozoon forward with a to-and-fro pendulum movement. This is the 
" pendulum swimming " phase. 

The first three of these types may be regarded as normal ; they take 
place in regular sequence in a fresh specimen ; the last two types are abnor- 
mal in fresh specimens, and indicate impaired ability to fertilize. Repeated 
observations should be made, if possible, in order to verify the findings in a 
given case. 

Treatment. — The treatment of sterility is as varied as the factors that pro- 
duce it and in many instances, as has been said, there is great difficulty in deter- 
mining the exact cause. When a pelvic examination discloses gross disease of the 
pelvic organs, the probable cause of the sterility is plain, and the treatment 

3 Semen, when freshly ejaculated, is exceedingly viscid and thick. After a time 
it undergoes rapid liquefaction. The progressive vibratile stage rarely becomes well 
established until after this change has occurred. 



604 GYNECOLOGY 

must be directed largely to the correction of the existing disorder. In such 
cases the indications are clear and well defined. The difficult cases are those 
in which sterility is absolute, and due either to developmental or to func- 
tional defects, and those in which the acquired lesions are so slight as to 
render their influence doubtful. In many instances the elimination of all 
possible abnormalities must be undertaken in the hope that the causative 
factor will be removed with the others. The developmental defects are, of 
course, the most difficult to cure. The deformity most amenable to treat- 
ment is anteflexion and stenosis of the cervix. For this dilatation and the 
introduction of a Norris stem may be curative. If, in addition, the vaginal 
cervix is elongated, or if it occupies an anterior position so that the external 
os is not in proper relation to the vaginal fornices, the lips may be split, as 
in Dudley's or Pozzi's operation, or Reynold's plan of lengthening the an- 
terior vaginal wall may be adopted. If the vaginal fornices are shallow, an 
attempt may be made to increase their capacity by the use of tampons, and 
the patient may be directed to elevate the hips during coitus, and to remain 
in that position for several hours afterward. Mechanical impediments to 
coitus in the vagina and vulva, such as rigid hymen, small introitus, septate 
vagina, or atresia, may occasionally be relieved by operation. A rigid 
hymen may be excised. A rigid narrow orifice that resists dilatation by 
means of specula can be enlarged by cutting the anterior border of the 
levator muscles and fascia in each sulcus, and suturing the incision in such 
a way as to make the division permanent. Vaginal septa should be ex- 
cised. A small, ill-developed uterus, even if no marked anteflexion or 
stenosis is present, may be increased in size, it has been asserted, by 
the introduction of the stem pessary. The intra-uterine galvanic elec- 
trode has been recommended, but it is troublesome to use, requiring 
rigid aseptic precautions, and is of doubtful efficiency. The advisa- 
bility of performing an operation for the correction of developmental defects 
in the hope that conception will subsequently occur must depend upon the 
condition of the genitalia as a whole (see Gynatresia, page 23). 

If the ovaries are small and poorly developed, the outlook is doubtful. 
Women with defective ovarian development usually begin to menstruate 
late, the periods being often irregular, delayed (five to eight weeks), and 
scanty. These functional indications of insufficient ovarian activity are fre- 
quently found in the excessively stout and in those exhibiting evidence of a 
faulty or perverted internal secretion from the thyroid, adrenal, and pituitary 
glands. Regular exercise, proper diet, reducing the weight, the applica- 
tion of the stem pessary, and the exhibition of ovarian or lutein powder, 
desiccated thyroids, and pituitary gland extract may be useful in some of 
these cases. 

When sterility is due to inflammatory disease of the lower genital tract, 
the treatment must be suited to the conditions present. (See the treatment 
of vaginitis, page 192; endocervicitis, page 224; endometritis, page 279; leucor- 
rhoea, page 197, etc.) An infected cervix or endometrium may be cured in 
obstinate and chronic cases by curetment followed by iodine or phenol 
applied locally ; if the external os is tight and the cervix is poorly drained, 
free lateral incisions may be made. Nabothian cysts may be punctured and 



STERILITY 605 

cauterized. In cervices that are greatly diseased partial amputation may be 
necessary. In obstinate leucorrhcea Reynolds especially recommends the 
use of powdered protargol insufflated into the vaginal fornices with a powder 
blower ; after the discharge becomes scanty and colorless, aristol is 
substituted. If the discharge is excessively acid, a normal salt or a sodium 
bicarbonate solution may be prescribed to be given in the form of a douche 
immediately preceding coitus. 

Needless to say, the proper treatment of gross pelvic diseases that may 
be the cause of sterility, operations for the removal of pelvic tumors (fibro- 
myoma, unilateral cystoma), resection or unilateral excision of an affected 
tube and ovary (hydrosalpinx, cystic ovary), or restoration to the normal of 
a displaced uterus may be followed by conception. Sterility due to retro- 
position of the uterus is often amenable to replacement and the use of a 
pessary. A submucous myoma or an endometrial polyp may admit 
of easy removal and be followed by conception. In these gross cases there 
is no question as to the advisability of operation and treatment, and the 
opportunity it affords. 

Among the most difficult cases are those in which no gross abnormality 
exists and still, from the entire aspect of the case, the presence of pelvic 
adhesions is suspected. Pelvic inflammatory disease may give rise to the forma- 
tion of adhesions that occlude the abdominal ostia of the tubes without leav- 
ing any evidence, on bimanual examination, of the true state of affairs. A 
history of pelvic infection, therefore, combined with one-child sterility, may 
be regarded as presumptive evidence of tubal adhesions if there is no other 
explanation of the sterility. In cases that have resisted all other plans 
of treatment, and in which pregnancy is greatly desired, the entire 
situation may be explained to the patient and her husband, and at their 
solicitation exploratory celiotomy may be performed for the purpose of 
directly inspecting the tubes and, if need be, opening them. 

When the tubes are found but slightly involved and the occlusion of 
the ostia is due to light and filmy adhesions, separation of the latter, fol- 
lowed by salpingostomy (see page 419), may effect a cure. If, however, 
evidences of serious trouble are found, the tubal wall being thickened and 
the mucosa atrophied, or the tubal plications largely destroyed or obliter- 
ated, operation does not promise much. In some unpromising cases, how- 
ever, pregnancy may follow excision of an outer more seriously diseased 
portion of a tube and the formation of a new ostium for the inner, less 
severely affected portion. 

In some cases light ovarian adhesions cannot be detected by bimanual 
palpation, and while their presence may be suspected, one cannot be certain 
as to their existence. They usually occur in conjunction with tubal adhe- 
sions. What has been said relative to exploratory celiotomy in suspected 
closure of the tubes applies equally well to the ovaries. The release of the 
ovary from adhesions may permit the rupture of follicles and the escape of 
ova which were previously lost. Operations upon cirrhotic ovaries or 
upon ovaries with thickened capsules or those the seat of numerous unrup- 
tured Graafian follicle cysts give little result. Excision of a corpus luteum 
cyst of the ovary, it has been claimed, has resulted in the resumption of 



606 GYNECOLOGY 

ovulation, which was temporarily inhibited by the persistent lutein tissue. 
If the diseased area is limited to one pole of the ovary, resection may im- 
prove the chance of conception (see page 418). Any operation on the tubes or 
ovaries for the purpose of removing adhesions and mechanical obstacles to the 
meeting of the ovum and the spermatic particles should be accompanied by thor- 
ough disinfection of the lower genital tract and excision of diseased tissue. 

Ovarian Transplantation. — It is conceivable that, in the case of very 
seriously diseased adnexa, when it is impossible to leave any of the ovarian 
tissue in situ, a portion of the ovary enucleated from the diseased mass 
(autograft) or a foreign ovary (heterograft) may be transplanted into the 
region of a resected and freshly opened tube, and, as a consequence, con- 
ception may subsequently occur. Such cases (all autografts) have 
been reported, but this possibility is so slight as to be almost undeserving 
of serious consideration. Nevertheless, in selected cases, with the patient 
fully cognizant of the facts, the procedure may, at her request, be tried. 6 

Artificial Insemination. — Artificial insemination may be practised in 
cases in which there is a good reason to believe that the semen does not 
enter the uterus. Certain cases of vaginismus, stenosis of the vagina, 
elongation, acute anteflexion, and contraction of the cervical canal may be 
indications for the adoption of this procedure. The semen is obtained im- 
mediately after ejaculation, kept warm, and about 0.5 c.c. of it is injected 
into the uterine cavity by means of a glass syringe with a long intra- 
uterine stem. A warm tampon covered with the remainder of the semen is 
placed against the external os, and the patient is kept in the recumbent 
posture with the hips elevated for twelve hours. Many successful results 
in the human have been reported, and it is well known that artificial im- 
pregnation is quite commonly resorted to in the breeding of horses. It 
should not be forgotten, however, that these animals are not sterile. 

6 Tuffier states that after transplantation, in favorable cases, the ovary lies dormant 
in its new position for several months, then becomes painful and swollen for a few 
days. These symptoms subside and five or ten days' later menstruation appears. This 
investigator endeavors to leave the uterus in situ. He transplants the ovary about 5 cm. 
from the abdominal incision subperitoneally. When possible, he uses both ovaries, and 
has not found any regularity or rhythm in the swelling of one or the other. In 19 of his 
earlier homotransplants — 145 altogether — he had only one failure — i.e., menstruation did 
not appear. He says that hot flashes and vasomotor phenomena are overcome by trans- 
plants. In some cases it has been found necessary to remove the grafted ovary, but 
the mere fact that it is transplanted does not make it any more likely 1 to undergo 
degenerative changes. 

Whitehouse reports one case in which the patient menstruated for a year after 
ovarian transplantation. He prefers " seedling " grafts, i.e., cutting the ovary into 
small pieces and placing these between the rectus muscle and the subperitoneal tissue. 
He places the ovary in Douglas' culdesac to keep it warm until he has finished his 
abdominal work. He draws the following conclusion, among others : . " It seems to 
be established that a small portion of ovary successfully engrafted anywhere furnishes 
to the subject of the graft the secretion or influence that preserves her sexuality and 
prevents atrophy of the genital^ organs and other changes in the individual that are 
coincident with complete castration." 

Heterotransplantation is not so successful as homo-transplantation. There seems 
to be a blood or tissue antagonism to hetero grafts. This is less marked in those of 
close consanguinity, and is not present in the case of homo-transplantations. 

W. L. Estes had two cases of pregnancy following homoplastic grafts. Morris 
had one case, believed to be the only one on record, of pregnancy following a 
hetero-transplantation. Morris and Frank each report cases of pregnancy following 
homoplastic grafts. 



STERILITY 607 

The most favorable time for practising artificial impregnation in the woman 
is immediately after or just before a menstrual period. Careful aseptic precau- 
tions must be observed, but antiseptics must, of course, be avoided. 

Artificial insemination is applicable to certain selected cases, and is 
likely to be efficient when other measures have failed provided there is some 
mechanical obstacle that cannot otherwise be avoided. 7 

Since one of the most frequent remediable causes of sterility appears 
to be stenosis of the cervix with anteflexion and a shallow vaginal vault, the 
patient in whom no gross disease can be demonstrated should be instructed 
to elevate the hips during coitus, and to remain in that position for at least 
twelve hours afterward. This prevents dissipation of the seminal lake, 
keeps the external os bathed in the semen for a longer period of time, and 
favors penetration of the spermatic particles. Intercourse should be limited 
to the first week after or the week before menstruation. Rohleder has 
recommended coitus on the last day of the period in sterile marriages with 
success. The alkaline menstrual blood is believed to be favorable to the 
life and activity of the spermatozoon. The husband should be instructed 
that frequent intercourse or multiplicity of ejaculation does not favorably 
influence the case. One completely physiologic coitus at the proper time is 
more valuable than numerous more or less abortive attempts. 

BIBLIOGRAPHY 

Bumm : " Uber Behand. u. Heilungsaussicht der Sterilitat bei der Frau." Deutsch. med- 

Woch., xxx, 1756. 
Chalfaxt, S. A. : " Subcutaneous Transplantation of Ovarian Tissue." Trans. Amer. 

Gyn. Soc., 1915, xl, 444. 
Frank, R. T. : "The Clinical Manifestations of Diseases of the Glands of Internal 

Secretion in Gynecological and Obstetrical Patients." Trans. Amer. Gyn. Soc, 1914, 

xxxix, 286. 
Goldberger, F. M. : " The Relation of the Cervix to Sterility and Pregnancy." Internat. 

Jour. Surg., 191 3, xxvi, 169. 
Graves, W. P. : " Sterility." Trans. Amer. Gyn. Soc, 1913, xxxviii, 526. 
Huhxer, M. : "The Practical, Scientific Diagnosis and Treatment of Sterility in the 

Male and Female." Med. Record. 1914, xxxv, 840; Ibid.: "Sterility in the Male and 

Female and Its Treatment." Rebman and Company, New York, 1913. 

7 Rohleder discusses the historic, moral, religious, economic, medicolegal, and tech- 
nical aspects of artificial impregnation and reproduction. He refers to- the necessity of 
examining both wife and husband, especially as regards venereal disease in the latter. 

Given favorable conditions, with an apparently unknown cause, with the exception 
of impotentia cceundi. etc., he has found reports in the literature of seventy-one cases 
treated by the so-called uterine method (injection of semen into the uterus), with 
twenty-five successes, and four cases treated by the vaginal plan (placing the semen in 
the vagina), with four successes. This makes a total of seventy-five cases with twenty- 
nine successes. Rohleder is willing to exclude ten cases reported by Girault, whose 
premises do not seem to be correct, and to accept as reliable sixty-five cases with 
twenty-one successes. 

His method is to obtain the semen immediately after a coitus, in the first day or so 
after menstruation, and, by means of a sterile and warm Braun syringe, to inject a few 
drops, if possible, into the uterine cavity; if this is impossible, the injection is made into 
the cervical canal. The remaining semen is placed on a warm tampon against the 
external os. The woman remains in bed for twenty-four hours, with knees together 
and pelvis elevated in order to retain the semen. 

In his own practice Rohleder has obtained one positive (delivery at term) and 
one presumable success; early absorption took place in six cases. The apparent cause 
of the trouble in the latter was stenosis of the cervix in two, and hypospadias in four. 
He regards this procedure with great favor. 



608 GYNECOLOGY 

Martin, F. H. : "Ovarian Transplantation." Trans. Amer. Gyn. Soc, 1915, xl, 33; Ibid.: 
" Ovarian Transplantation in the Lower Animals and Women." Surg., Gynec. and 
Obst, 1911, xiii, 53; Ibid. : "Progress in the Study of Ovarian Transplantation and 
Ovarian Secretion." Trans. Amer. Gyn. Soc., 1917, xlii, 257. 

Noble, C. P.. " Salpingitis and Sterility." Trans. Amer. Gyn. Soc, 1891, xvi, 480. 

Noegerrath, E. : Die latente Gonorrhea in weiblichen Geschlecht. Bonn, 1872. 

Polak, J. O. : "A Study of the Pathology in Its Relation to the Etiology with the 
End Results of Treatment of Sterility." Trans. Amer. Gyn. Soc, 1916, xli, 598. 

Prochownik, L. : " Ein beitrag zu den Versuchen kunstlicher Befruchtung beim Men- 
schen." Centralbl. f. Gynak., 191 5, xxxix, 145. 

Reynolds, E. : " The Theory and Practice of the Treatment of Sterility in Women." 
Jour. Amer. Med. Assn., 1913, lx, 93; Ibid.: "The Principles Underlying the Successful 
Treatment of Sterility in Women." N. Y. State Jour. Med., 1914, xiv, 4; Ibid. : "The 
Causes and Treatment of Sterility in W r omen." Amer. Jour. Med. Sci., 1907, cxxxiv, 
209 ; Ibid. : " Forward Fixation of the Cervix as Predisposing Cause of Some Retro- 
deviations of the Uterus. Operation for Its Release." Surg., Gynec and Obst., 1914, 
xix, 588 ; Ibid. : " Fertility and Sterility." Trans. Sec. Obst., Gyn. and Abdom. Surgery, 
A. M. A., 1916, 17. 

Rohleder, H. : Die Zeugung beim Menschen ; Mit Anhang ; die kiinstliche Zeugung 
(Befruchtung) beim Menschen." Thieme, Leipzig, 191 1. 

Runge, E. : " Beitrag zur Aetiologie and Therapie der Weiblichen Sterilitat." Arch, f . 
Gyn., 1909, lxxxvii, 572. 

Tuffier, T.: "Transplantation of the Ovaries." Surg., Gynec and Obst., 1915, xx, 30; 
Ibid. : " Les Graffes Ovariennes Humaines ; Suites eliognes." Jour. d. Chir., 1913, x, 

P- 529- 
Whitehouse, B. : " The Autoplastic Ovarian Graft and Its Clinical Value." Clin. Jour., 
1913, xliii, 107. 



CHAPTER XXXIV 

HYGIENE AND THE RELATION BETWEEN NERVOUS AND 
GYNECOLOGIC DISORDERS 

THE HYGIENE OF ADOLESCENCE 

There is not so much difference in the physical inclinations of the male 
and the female before, as there is after, puberty. During childhood the 
average healthy girl will be quite as active as a boy, although her activities 
may be along less boisterous channels. Puberty begins earlier in the female 
than in the male, and coincident with it there are instinctive changes in 
deportment and in inclinations. Although in healthy individuals there may 
be a disposition to give up some of the physical activities of childhood, the 
sexual development will not lead to serious or morbid introspection. There 
may be a slight indisposition about the menstrual periods, but when this has 
passed there will be no pelvic symptoms or indications until the next period 
is due. Inherited physical or mental weakness, improper hygiene, faulty 
habits of dress, too little exercise in the open air. ill-chosen diet, hard work, and 
mental anxiety may decidedly interfere with the healthy normal condition. 
The menstrual periods may be excessively painful, and with it leucorrhoeal 
discharge, backache, disinclination for exercise, and morbid introspection 
may make their appearance. 

The importance of exercise for the young woman can hardly be overesti- 
mated (see page 710). The muscles are vitally concerned with many of the 
metabolic processes, and the normal heat production, the expenditure of energy. 
the proper circulation of the blood, and the excretory activities depend largely 
upon healthy muscles and muscular contractions. The demands of the muscular 
system are not always to be found in performing household duties and never 
in the duties of the school-room. For that reason the young woman should 
be encouraged in all suitable outdoor sports, such as walking, tennis, basket- 
ball, bicycling, rowing, skating, horseback riding, and the use of dumb-bells 
or of Indian clubs. A healthy body is conducive to a healthy mind. School 
hours should never be allowed to interfere with daily exercise in the open air. 

The diet is of considerable importance ; the food should be plain and 
wholesome, and tea, coffee, candy, condiments, and alcohol in any form 
should be restricted. 

In a healthy woman there need be no variation in the daily routine at the 
menstrual period. Exposure to cold and dampness should be avoided; tub- 
baths are usually contraindicated at this time, and shower- or sponge-baths 
should be substituted. To those women who experience more or less pain, 
rest and quiet will prove grateful. 

Young unmarried virginal women who exhibit symptoms of pelvic dis- 
orders necessitating an examination should not be dealt with in the ordi- 
nary way. In selected cases a gentle, careful bimanual pelvic palpation may 
be attempted without anaesthesia, and inspection of the vaginal cervix and 
39 609 



610 GYNECOLOGY 

fornices may be made with a large Kelly cystoscopic speculum, with the 
patient in the knee-chest or the Sims' position. Anaesthesia is usually re- 
quired and generally advisable, and should be used except in simple and 
generally favorable cases (see Chapter VIII, page 112). Uncertain and 
equivocal diagnoses should not be rendered to young women, nor should 
tedious methods of treatment be employed for a local pelvic disorder. The 
patient should be dealt with by general measures or by operation. Local 
treatment is never justifiable in young virgins, and elusive and ambiguous 
terms, such as " congested ovaries," " stricture of the womb," etc., should 
never be mentioned to them. By adopting such a course there will be less 
danger of inducing morbid introspection and of engendering a psychosis 
that cannot fail to have an unfavorable effect upon the patient. 



THE RELATION OF NEUROSES TO PELVIC DISEASES 

The importance of pelvic disease in the production of neuroses in women has 
been greatly exaggerated. Pelvic disease in itself does not excite a neurosis, but 
the influence of a pathologic condition in the pelvis on the general health in a 
neurotic subject may predispose to the formation of one. In neurotic women 
the nervous condition may be associated with faulty general development in 
which the pelvic organs share. Thus, if a neurosis is combined with poorly 
developed or improperly formed pelvic organs, the neurosis may be de- 
pendent upon the same cause as the imperfect development of the pelvic 
organs, but one does not depend primarily upon the other. As a conse- 
quence of the physical and nervous disability, the most striking and impor- 
tant function of the female, menstruation, is incompletely or painfully per- 
formed. The importance that the patient attaches to the menstrual func- 
tion and the anxiety aroused by any abnormality concerning it may influence 
the neurosis secondarily through psychic impression. 

A neurosis in which pelvic pain that has no anatomic foundation is com- 
plained of has no more significance than a neurosis that produces pain in 
other parts of the body or in persons of the opposite sex. In women pain 
that is purely neurotic in type is more likely to be referred to the pelvis 
than to any other part of the body. This naturally leads to the fear that the 
pelvic organs are diseased, but it must be remembered that the symptoms 
may be purely neurotic and compatible with absolutely healthy pelvic organs. 
Such symptoms as dysmenorrhcea, backache, or dragging pain in the lower 
abdomen may be present without any anatomic or other recognizable cause. 

On the other hand, neuroses may exist with actual acquired lesions of 
the pelvic organs. These lesions, through the suffering they occasion, may 
exaggerate the neurosis to a certain extent, and when they are cured, the 
patient's condition may improve to a similar degree. 1 

1 Graves distinguishes two types of " genital psychoneurosis " : the first, in which 
there is a condition of mind continually reverting to imaginary ills in the pelvic organs. 
he calls the " genital neurosis of imagination"; the second, in which the mind reverts 
to real pelvic disorders, he terms the " genital neurosis of overvaluation." The first 
belongs to the neurologist and the psychiatrist ; the second belongs first to the gynecologist, 
and later to the alienist. 

In the first, the individual is conscious of functions that normally " belong to the 



NERVOUS AND GYNECOLOGIC DISORDERS 611 

From these facts it is apparent that when neurotic persons complain of 
pelvic symptoms, it is very important to make a thorough examination, 
under anaesthesia, if necessary, to determine once and for all whether any 
pelvic lesion exists. If a lesion is present, it should be corrected at once; if 
there is not a lesion, or if it is of such a doubtful character that the physician 
is uncertain, the patient should positively be assured that her pelvic organs 
are healthy and her mind thus set at ease (see also pages 112 and 610). 

Women with neuroses should never be subjected to local treatment un- 
less they have a real pelvic lesion, and one that is quickly and certainly 
amenable to local treatment. When a neurosis coexists with actual pelvic 
disease, the patient should be subjected to the most effectual treatment 
known for the condition, whatever it may be, whether medical or surgical. 
In treating all neurasthenic or neurotic patients the physician should be 
very careful not to use terms that may fill the individual with morbid 
apprehension. The use of such expressions as " congestion of the ovary," 
" neuralgia of the ovary," and " ulcer of the womb," should be avoided. 

INSANITY IN ITS RELATION TO GYNECOLOGY 

Insanity is a disease of the nervous system. It is usually entirely independent 
of disease of the generative organs. It may be complicated by disorders of the 
sexual organs, or the latter, by their influence upon the general health, may favor 
the development of insanity, more especially in neuropathic women. When in- 
sane women present symptoms of disease of the sexual organs, it is advis- 
able to have an examination made by an expert gynecologist, so that a 
correct diagnosis of the condition of these organs may be made. Insane 
women whose sexual organs are normal, are in no sense gynecologic cases, 
and should receive treatment directed to the mental condition alone. 

On the other hand, an insane woman whose sexual organs are the seat of 
a disease that impairs her physical well-being, or that threatens her life, 
should receive the same treatment that would be indicated if insanity did 
not exist as a complication. When the history shows that the disease of the 
sexual organs antedated the mental disorder and that it has undermined the 
health of the patient, and particularly the stability of the nervous system, 
gynecologic treatment is much more strongly indicated than in the class of 
cases previously considered. In such cases, even more than in those of the 
first class, there is reason to expect that the cure of the pelvic disease may 
exert a favorable influence upon the mental condition and may assist in 
restoring the patient's sanity. 

From the investigations of Taussig and the report of Gibson, little im- 
provement has been noted after the operative correction of pelvic disorders 
in patients exhibiting some form of dementia, such as dementia prsecox, 
general paresis, epilepsy, and senile dementia. 



realm of the subconscious," such as movements of the intestines, heart, and stomach, the 
attention having been directed to them accidentally or by pain or some temporary aberra- 
tion of function. 

In the second the pelvic lesion is apt to be a minor one, which, " without causing 
severe symptoms, maintains a nagging discomfort and keeps the searchlight of attention 
constantly turned upon them." Among them may be mentioned pelvic adhesions and 
descensus of the uterus. 



612 GYNECOLOGY 

On the other hand, in those forms of insanity in which dementia does 
not appear, manic-depressive insanity, melancholia, and paranoia, the patient 
may be benefited by surgical treatment; this is especially true in cases of 
manic-depressive insanity. 

Insanity is one of the least common post-operative complications, and 
occurs after operations upon the sexual organs with about the same relative 
frequency as it does after operations upon other parts of the body. It occurs 
as frequently in the male as in the female. 

The usual type of mental disease that developes after operation is that 
known as confusional insanity. Neuropathic individuals and those who 
have undergone great physical or mental strain before operation are those 
in whom insanity is most apt to develop, especially if annoying and per- 
sistent painful symptoms make their appearance after operation ; for ex- 
ample, such symptoms as infection of the bladder, leading to frequent and 
painful urination, and infection elsewhere, necessitating the use of dress- 
ings, with long-continued pain and annoyance incident to them. In certain 
cases there is no doubt that the insanity is toxic in nature and due to infec- 
tion, but in most instances it appears to be due to a disturbance of the 
mental equilibrium, brought about by the stress and strain attending the 
operation, superadded to worry, grief, or mental excitement antedating the 
surgical procedure. Trifling operations are as apt to be followed by in- 
sanity as are those of a graver type. In Noble's experience, insanity has 
usually followed plastic operations and has almost never complicated hys- 
terectomy or ovariotomy. 

Confusional insanity arising after operation in a woman who possessed 
a normal or a fairly normal mind previous to the operation, usually ends in 
recovery within six weeks or sooner. In Noble's experience, comprising 
about twenty cases, one was fatal ; the others ended in prompt recovery. 
These general principles may be regarded as a summary of the present 
views of both alienists and gynecologists concerning the relation of insanity 
to gynecology. 

BIBLIOGRAPHY 

Broun : " Preliminary Report of the Gynecological Surgery in the Manhattan State 

Hospital, West." Trans. Amer. Medico-Psychological Assoc, 1005. 
Gibson, G. : " Gynecological Operations Upon the Insane." N. Y. Med. Jour., 1915, 

ci, 293. 
Hobbs : " The Relation of Insanity to Pelvic Diseases and Other Lesions." Amer. Jour. 

Obst, 1900, lxi, 1. 
Manton, W. P.: "The Relations of Visceral Disorders to the Delusions of the Insane." 

Amer. Jour. Obst., N. Y., 1896, xxxiv. 
Rohe: "The Relations of Pelvic Disease and Psychical Disturbances in Women." Amer. 

Jour Obst, 1892, ii, 694. 
Smith, R. R. : "Notes on the Relationship Between Gynecology and Neurology." Trans. 

Amer. Gyn. Soc, 191 5, xl, 150. 
Taussig, F. J. : " Gynecologic Disease in the Insane and Its Relationship to the Various 

Forms of Psychoses." Jour. Amer. Med. Asso., 1912, lix, 713. 



CHAPTER XXXV 

THE SELECTION AND PREPARATION OF PATIENTS FOR 

OPERATION 

THE SELECTION OF CASES 

Few operations undertaken for lesions of the generative tract are de- 
manded suddenly or must be immediately executed. Most of them are 
planned deliberately and carried out at a set time. A few gynecologic dis- 
eases necessitate immediate operation ; others may require it only within a 
limited time. In some the symptoms may be relieved by palliative meas- 
ures, and operative treatment may be deferred according to the will of 
the patient. In many cases the operation is elective. It is, therefore, 
necessary for the physician to be able to determine when operation is indi- 
cated and when it may be delayed ; when it is imperative, and when it is a 
matter of choice ; which case must be handled surgically, and which will 
derive all possible benefit from non-operative treatment. The disease itself, 
the age, the general health, and the social position all have a bearing on 
these points. The choice between operative and non-operative treatment 
will often depend upon the circumstances surrounding the case. 

Those diseases that usually require operation as soon as they are dis- 
covered include ectopic pregnancy, ovarian cysts, and malignant disorders 
in the early stage. Myomata of the uterus do not always demand treat- 
ment, but a great majority of them must sooner or later be subjected to 
radical surgical, radium, or Rontgen ray treatment. 

Displacements of the uterus or lacerations of the cervix and perineum 
may require immediate operation during the child-bearing period if they 
are productive of marked suffering, and especially if the patient is un- 
likely to bear more children. If, however, the opposite is true, the patient 
may be tided over the active child-bearing period by adopting palliative 
measures, and as the reproductive age draws to a close operation may 
be undertaken. (See Treatment of Retroflexion, page 247.) In the extreme 
cases of prolapse seen in advanced years an effort should be made to relieve the 
patient by the use of a suitable pessary, in order to avoid an operation that 
is contraindicated by the age or the general condition. 

In pelvic inflammatory diseases the patient should not be operated upon 
during the acute stages, whether they are of gonorrhceal, puerperal, or of 
surgical origin. It is always safer to wait until the infection has subsided, 
and the morphologic changes, the result of acute exudation and infiltration, 
have disappeared. The indication for operation in an inflammatory disease 
after the lesion has become chronic is somewhat dependent upon the ex- 
tent of the lesion, the number of attacks of pelvic peritonitis that the patient 
has undergone, the symptoms which she presents, and the time that she 
can afford to consume to get well. Unless the patient earnestly desires to 

613 



614 GYNECOLOGY 

avoid an operation and is willing to remain an invalid for a considerable 
time, and to carry out certain palliative measures every day, operation should 
be performed as soon as the chronic stage has been reached. 

Dercum has shown that operations on the pelvic and other viscera for 
the relief of functional nervous disorders have no justification. This em- 
phasizes the desirability of making a very careful diagnosis of the lesions in 
any case exhibiting neuroses. Only in this way will operations that are 
without benefit be avoided. 

THE EXAMINATION AND TREATMENT OF PATIENTS PREPARATORY TO OPERATION 

The physical and mental condition of every patient should be carefully 
investigated before operations of election. Since general disorders may be 
responsible for many, if not all, of the symptoms for which she seeks sur- 
gical advice, it is important that none be overlooked, lest the patient expect 
too much from the operation or be disappointed in the result. Certain die- 
eases also contraindicate or rer.der operation hazardous, and make it ad- 
visable to limit the procedure as much as possible, or to carry it out with 
additional precautions and safeguards. Care in the execution of the pre- 
paratory examinations and treatment will sometimes disclose unsuspected 
lesions, and in this way loss of life or, at least, unfortunate complications 
or sequelae to operative treatment may be prevented. 

The diseases that contraindicate operation, unless the procedure is 
urgently demanded to save life, include severe diabetes mellitus, Addison's 
disease, advanced and active tuberculosis, advanced cardiac, hepatic, or renal 
disorders, chronic alcoholism, etc. Anaemia, hepatic or renal inactivity, un- 
healthy conditions of the skin, chronic constipation, moderate degrees of 
cardiac insufficiency, nervous exhaustion, and mental fatigue or excitement 
may make it desirable that considerable time be spent in preparing the 
patient for the ordeal which she is about to undergo. 

The condition of the part or parts to be operated on may often be im- 
proved to a considerable extent by rest in bed, the use of hot douches, and 
the application of suitable remedies. Thus subinvoluted uteri and ©edema- 
tous vaginal walls may be depleted and erosions of the mucosa may be 
healed. The surgeon should always endeavor to place the operative area 
in as healthy and aseptic a condition as possible before undertaking the 
surgical measures. 

In certain pelvic inflammatory cases it may be some time before the 
infectious properties of the invading bacteria are destroyed and the inflam- 
matory exudate is absorbed. Although this may require several weeks or 
months or even longer, the time will be well spent (pages 415 and 425). To 
this end patients should be kept in bed, or at partial rest, and the particular 
condition should be treated secundum artem until the general and the local 
condition have returned as nearly as possible toward the normal before the 
operative treatment is carried out. Thus chronic constipation and intestinal 
and hepatic inactivity may be overcome and a weakened circulation may be 
so fortified that all symptoms of insufficiency will disappear. In anaemic 
patients the condition of the blood may be improved, a chronic bronchitis 



SELECTION AND PREPARATION OF PATIENTS 615 

may be cleared up, and sluggish kidneys may be aroused to renewed activity. 
The mental attitude of the patient may be changed from one of terror and 
apprehension to one of patient confidence, and the exhausted and weakened 
nervous system may be rejuvenated. The individual should be placed in all 
respects in the best possible condition to secure rapid convalescence and 
to promote healing. 

Cardiac Risks. — The individual cardiac lesion is of less importance than 
the condition of the heart muscle and the degree of compensation. An 
operation done under the most favorable conditions of modern surgery may 
be regarded as the equivalent of a very moderate unusual exertion 
(Reynolds). The patient should be studied in consultation with an internist, 
and if practicable, with the anaesthetist. With rest, suitable food, and the 
use of strophanthus or digitalis the patient should be kept under observa- 
tion until compensation is reestablished. " A subject of valvular or other 
cardiac disease, who is able to go up a flight of stairs at an ordinary walk 
without provoking more than slight breathlessness, is fitted to endure an 
abdominal operation of average grade without suffering any grave increase 
of the ordinary risks " (Reynolds), provided expert medical care before and 
after operation, thoroughly expert anaesthesia, and rapid, gentle operating- 
are provided. 

Anaesthesia should be preceded by the administration of morphine and 
atropin or scopolamine. Nitrous-oxide-oxygen anaesthesia without ether. 
or with as little as possible, should be used, with local novocaine infiltra- 
tion of the operative area (see Crile's technic, page 617). The anaesthesia 
should be started with the patient in the reclining position. 

During the early stages of the anaesthesia struggling and cyanosis are 
especially to be avoided. The Trendelenburg posture should not be em- 
ployed, or if its use becomes necessary, it should be limited to a few minutes. 
During the greater part of the operation the table should be level and the 
shoulders of the patient should be slightly raised. Pressure on the abdom- 
inal viscera should be avoided ; exposure and handling of the intestines 
should be limited. That plan of operation should be selected that can be con- 
summated with a maximum of speed and a minimum amount of traumatism. 

If symptoms of right-sided cardiac hypertension or acute dilatation (rise 
of pulse-rate, cyanosis, etc.) supervene, prompt phlebotomy, digalen and 
camphor, oxygen, and small doses of morphine, together with surface heat 
applied locally, constitute the treatment. When large intra-abdominal 
tumors have been removed, compensatory support and pressure should be 
maintained during the first few days of the convalescence. 

Following the operation the patient should be closely observed by the 
internist, and her treatment should be directed in cooperation with him. It 
is most desirable to avoid excessive vomiting and distention of the stomach 
or intestine. This can usually be secured by careful pre-operative empty- 
ing of the gastro-intestinal tract and strict regulation of diet. If they 
should, nevertheless, develop after operation, such symptoms must be met 
promptly but with the most gentle measures that are effective. 

Anaemia Risks. — Anaemia carries with it a certain operative risk, de- 
pending, of course, upon its degree and upon the associated conditions that 



616 GYNECOLOGY 

obtain in the individual patient. The principal causes of anaemia in gyne- 
cologic cases have been discussed elsewhere. 

In a few cases it is possible to restore the blood-picture to the normal by 
suitable pre-operative treatment. In others such a fortunate outcome is not 
possible, since the etiologic factors of the anaemia — hemorrhage and toxaemia 
— will persist until the operation is performed. Nevertheless, in almost all 
instances, except when the operative procedure is to be trivial, the condition 
of the patient should be improved to the maximum degree. In the case of 
myomata that bleed periodically, suitable regulations and treatment (de- 
scribed on page 310) will greatly improve, and in some cases actually restore, 
the condition of the blood. In anaemic cases with menorrhagia the best time 
for undertaking the operative procedure should be just before a menstrual 
period is due. When anaemia is due either in part or in whole to toxaemia, 
especial steps should be taken to minimize the absorption of septic products 
and to increase the eliminating functions of the body. 

Anaemia is to be regarded as especially hazardous from the operative 
standpoint when the haemoglobin falls to 40 per cent, or lower. In a re- 
view of the material at the Johns Hopkins Hospital, Cullen found that in 
the period from 1889 to 1912 there had been 170 cases of that description. 
Seven were unfit for operation and died without it ; in three the myomatous 
disease and the anaemia were the direct cause of death ; in four others com- 
plications (toxic absorption, etc.) were present. Thirteen cases died after 
operation, death being due to peritonitis, intestinal obstruction, circulatory 
failure, etc. One hundred and fifty-two cases recovered, the haemoglobin in 
them varying from 40 to 10 per cent, as follows: 

40 to 36 per cent 49 cases 

35 to 31 per cent 30 cases 

30 to 26 per cent 29 cases 

25 to 20 per cent 30 cases 

Below 20 per cent 14 cases 

152 

In serious cases transfusion should be a routine procedure either before 
or after operation; as simplified by Bernheim, it can be carried out in from 
twenty to thirty minutes. Every surgeon should familiarize himself with 
the technic of blood transfusion. 

The resistance of anaemic patients is usually much impaired, and the 
post-operative treatment should be regulated accordingly. The patient 
should be disturbed as little as is consistent with careful stimulation 
and support. 

Blood-pressure Risks. — High blood-pressure (hypertension) and low 
blood-pressure (hypotension) increase the dangers of ration and predis- 
pose the patient to apoplexy, embolism, thrombose, renal insufficiency, 
angina, pneumonia, and cardiac failure. The pulse-pressure reading (i.e.. 
the difference between the systolic and thp ^istolic) is to a certain extent a 
more reliable index of these conditions th. i is the systolic maximum. 

Hypertension may be temporary and remediable, or permanent and 
irremediable. Hypertension is caused by continued and intense emotions, 
such as worry, grief, and anger, acute or chronic infections, exophthalmic 



SELECTION AND PREPARATION OF PATIENTS 617 

goitre, increased intracranial pressure, cardiovascular disease, and physical 
changes in the walls of the blood-vessels. 

While the hazard of hypertension must at times be undergone, as a rule 
the operation may be delayed until the risk is eliminated or at least much 
reduced. In the case of continued emotional disturbance, the plan of treat- 
ment will be obvious : in Graves' disease, lobectomy or ligation ; in toxaemia, 
the control or eradication of acute or chronic infection ; and in cardiovascu- 
lar cases, as indeed in all cases, a meat-free diet, rest, nitroglycerine, and 
diversion are indicated. 

Hypotension cases are principally those associated with hemorrhage and 
anaemia. These should be treated as has been described. Here transfusion 
is a sovereign remedy when the operation cannot be deferred. 

Crilc's Anoci Association. — In performing operations upon cases of hy- 
pertension and hypotension, the procedure of Crile, known as anoci asso- 
ciation, should be followed. His own description of this method is 
as follows : 

" Our complete technic in abdominal operations is as follows : When the 
pre-operative strain is great, an hour or so before the operation we admin- 
ister to the patient a hypodermic injection of yi of a grain of morphine and 
i 150 of a grain of scopolamine, that he may receive the solace and quiet 
which come from the use of these drugs. The inhalation anaesthetic may 
be administered in the patient's room ; or else in the apathetic state produced 
by the morphine and scopolamine, the patient, with eyes and ears closed to 
external impressions, is conveyed to the operating room, where a specially 
trained anaesthetist administers nitrous oxide. When the patient is anaes- 
thetized, the division of tissue is preceded by nerve blocking by means of 
the local administration of 1 : 400 novocaine. Each division of tissue in the 
course of the operation is preceded by the infiltration of this local anaes- 
thetic, the blocking being made so complete that no nerve is left free to 
carry a single activating impulse to the brain. First the skin, therefore. 
then the subcutaneous tissue, then the fascia, and finally the remaining 
muscle or posterior sheath and the peritoneum are in turn no\'ocainized, 
subjected to momentary pressure to spread the anaesthetic, and then divided 
within the blocked zone. If the blocking has been complete, then upon 
opening the abdomen there will be found no increased intra-abdominal 
pressure, no tendency to expulsion of the intestines, and no muscular rigidity. 

" The peritoneum is next everted, and a 0.5 per cent, solution of quinine 
and urea hydrochloride is massively infiltrated at a distance from the in- 
cision about the line of proposed sutures, and as before, the parts are then 
subjected to momentary pressure. This infiltration serves as a block, and 
as its effects last r everal days, it should prevent or at least minimize the 
post-operative woun. pain and the post-operative gas pain, and thereby 
minimize post-operative shock. Quinine and urea cause a certain amount 
of oedema of tissue which las for some time after the wound is healed. 
The relaxed abdominal wall w.* permit exploration of the entire abdominal 
cavity with ease. If there is no cancer nor acute infection in the field of 
operation, then the following regions may be blocked as completely and in 
the same manner as the abdominal wall — the mesoappendix, the base of the 



618 GYNECOLOGY 

gall-bladder, the uterus, the broad ligaments and the round ligaments, the 
mesentery, and any portion of the peritoneum. After a hysterectomy the 
stumps may be completely infiltrated with quinine and urea hydrochloride, 
thus giving a degree of anaesthesia for at least two days. On account of 
the absence of nociceptors, operations on the stomach and intestines made 
without pulling on their attachment cause no pain, and hence the novocaine 
infiltration of these viscera is not required. If the brain has received no 
stimuli during the operation, then the closure of the upper abdomen is as 
easy as the closure of the lower — all is done with the ease of relaxation. 
What is the result? No matter how extensive the operation, no matter 
how weak the patient, no matter what part is involved, if anoci technic is 
perfectly carried out, the pulse-rate at the end of the operation is the same 
as, at the beginning. The post-operative rise of temperature, the accelera- 
tion of the pulse, the pain, the nausea, and the distention are minimized or 
wholly prevented. 

" As the operation does not end in the operating room, so the protective 
effects of this technic follow the patient to his room, and help him far on 
the road to easy recovery. Post-operative pain is wholly eliminated if 
quinine and urea hydrochloride are injected into the entire wound ; post-operative 
gas pain is largely or wholly prevented ; painful scar is eliminated ; and 
post-operative nervousness and aseptic wound fever are avoided. The pa- 
tient quietly, with care-free mind and comfortable body, passes quickly to 
complete recovery from the disease, at least, for which operative procedure 
was required, while the very condition which made an operation seem a 
menacing danger may also have been relieved." 

Kidney Risks. — Under kidney risks may be grouped those cases that 
show kidney insufficiency and those that show the presence, in the urine, of 
some constituent that is indicative of metabolic disturbance. 

A small amount of albumin and a few hyaline casts in the urine do not 
contraindicate operation, but call for the exhibition of water and the regula- 
tion of the diet, and indicate that the operation should be delayed until the 
urine has cleared up or until functional tests show that the kidney excretion 
is within the bounds of safety. 

Granular casts, except in very small numbers, indicate a more active and 
recent lesion of the kidney, and imperatively demand preparatory treatment; 
thus rest in bed, a milk diet, and a simple diuretic will, in a majority of 
cases, result in rapid improvement and a disappearance from the urine of 
the abnormal constituents. Nevertheless, in such cases, the tests of the 
functions of the kidney should always be made. Albuminuria without casts 
means excessive consumption of animal food or contamination of the urine 
with pus or blood — the source of the latter must be determined, and a fil- 
tered specimen examined for albumin, in order to determine whether the 
albumin is excreted with the urine or is due entirely to the admixture with 
Hood or pus (see ratio of albumin to pus corpuscles per cubic centimeter, page 
no). Albuminuria without casts, except as the result of errors in diet, is 
very unusual. 

Indican in the urine is an indication of intestinal torpor and absorption. 
It usually disappears after thorough catharsis and evacuation of the 
intestinal tract. 



SELECTION AND PREPARATION OF PATIENTS 619 

Bile in the urine indicates the presence of hepatic or biliary complica- 
tions — it has no significance beyond that of the lesion which produces it. 

Acetone in the urine is an evidence of a disturbance of metabolism, and 
is found in starvation, carcinoma, high fever, glycosuria, and diabetes. 
It is an important finding, and demands careful investigation and treatment. 
Aside from the significance and treatment of the underlying cause, patients 
with acetonuria should receive sodium bicarbonate by the mouth, and be- 
fore proceeding with an operation enteroclysis or intravenous injections 
should be given until the symptom disappears. After the operation the 
sodium should be given in order to obviate the development of acetonuria, 
which is particularly prone to develop in such subjects after ether or 
chloroform narcosis. 

Diacetic acid has the same import as acetone in the urine, but to a 
greater degree. It is most frequently found in diabetes or in connection 
with serious metabolic disturbance of the liver; occasionally its presence 
may be explained by a marked decrease in the ingestion of carbohydrates. 
As with acetonuria, the significance and the treatment vary with the 
underlying lesion. 

Sodium bicarbonate should be used freely in the pre-operative and post- 
operative treatment. 

In operations that involve the kidney itself, and especially in nephrec- 
tomy, an estimation of the renal function is particularly important. (For a 
discussion of the question see Tuberculosis of the Kidney, Chapter XXV, 
page 477; also Chapter IX, page 158.) 

An abnormality in the urinary constituents and a moderate diminution 
in the kidney function need not be regarded as contraindicating a contem- 
plated operation that will rid the patient of a lesion that has predisposed to 
or aggravated the kidney disorder (e.g., the removal of a pelvic tumor that 
presses upon the ureter, etc.). Under these circumstances medicinal treat- 
ment alone will not suffice to clear up the condition. 

BIBLIOGRAPHY 

Berxheim, B. W. : Blood Transfusion, Hemorrhage and the Anemias. Lippincott, 

Phila., 1917. 
Brackett, E. G., Stoxe, J. S., and Low, H. C. : " Aciduria (Acetonuria) Associated with 

Death after Anaesthesia." Boston M. and S. Jour., 1904, cli, 2. 
Crile, G. W. : " The Newer Methods of Reducing the Mortality of Operations on the 

Pelvic Organs." Trans. Sect. O., G. and A. S., A. M. A., 1913, 37 : Ibid. : " The 

Relation between the Blood Pressure and the Prognosis in Abdominal Operations." 

Trans. Am. Gyn. Soc, 1913, xxxviii, 179. 
Cullen, T. S. : " Operations on Patients with a Hemoglobin of 40 per cent, or less. ' 

Trans. Am. Gyn. Soc, 1913, xxxviii, 248. , 
Faught, F. A. : Blood Pressure. Saunders, Phila., 1916. 
Flexxer, S. : "A Statistical and Experimental Study of Terminal Infections." Jour. Exp. 

Med., 1896, ii. 
Freuxd: Beziehungen der weiblichen Geschlechtsorgane zu andern Organen. Lubarsch 

u. Ostertags Ergebniss den allgemeines Pathologie, Wiesbaden, 1898. 
Freuxd, H. A. : " The Diagnostic Value of the Electro-Cardiograph before Gynecological 

and Obstetrical Operations." Trans. Am. Gyn. Soc, 1913, xxxviii, 210. 
Noble, C. P. : " Personal Experience in Operations Upon Diabetic Patients." Amer. Med., 

1903, vi, 13. 
Polak, J. O. : " The Conduct of Gynecological Operations in the Presence of Acute and 

Chronic Endocarditis," Trans. Am. Gyn. Soc, 1913. xxxviii, 112. 
Reynolds, E. : " Conduct of Gynecological Operations in the Presence of Chrome Affec- 
tions of the Heart." Trans. Am. Gyn. Soc, 1913, xxxviii, 368. 



CHAPTER XXXVI 
OPERATIVE TECHNIC 

The technic of an operation comprises, first, the methods used in the 
preparation of the patient, the operative area, the operator and his assistants, 
and the operating room ; the sterilization of the instruments, the dressings, 
and the utensils that are to be used in the course of the operative procedure. 

The principle underlying operative technic is that of asepsis — that is, the 
exclusion of infectious agents from the field of operation. To this end those 
who are directly concerned with the operation, the room in which the opera- 
tion is to be done, and the utensils or the dressings that are used must be 
suitably prepared and protected from contamination during the course of 
the operation. 

GENERAL PREPARATION OF THE PATIENT 

It is important to have the gastro-intestinal canal empty or nearly so. An 
active cathartic should be given twenty-four hours (in lower intestinal, sigmoid 
and rectum cases, thirty-six hours) before the time set for the operation. Castor- 
oil, i fluidounce, or one or two compound cathartic capsules x are the most effec- 
tive. Thereafter the diet should be liquid, or at most semi-solid, and easily diges- 
tible. At least three hours before the time set for operation an enema of epsom 
salts (2 ounces), glycerine (2 ounces), sweet oil (4 ounces), and water (1 pint) 
should be injected into the sigmoid by means of a rectal tube. After the 
bowels have ceased to act, the rectum should be irrigated with salt solu- 
tion until the water returns clear. 

No food, liquid or solid, should be given within twelve hours of the 
operation, although an occasional sip of water or of weak tea may be al- 
lowed. If the operation threatens to involve the upper intestinal tract or 
the stomach, for three days preceding the operation the food and drink 
should be as nearly sterile as possible (boiled water and milk; cooked or 
roasted food served hot). 

An antiseptic mouth-wash and a tooth-brush should be used several 
times a day, and if there is any likelihood of food retention, lavage may be 
practised just before the anaesthetic is administered. The night before the 
operation the patient should be given a full bath, with special attention to 
the axillae, umbilicus, and pubes. Fresh night-clothes and a change of bed 
linen should be provided. 

PREPARATION OF THE OPERATIVE AREA 

Perineal Operations. — The hair about the pubes and vulva should be re- 
moved with scissors and safety razor. If the operation is solely a perineal 

1 I£ Ext. colocynthidis comp g r# j 1/^ 

Hydrarg. chloridi mitis g r . Ij 

Resin. Jalapae gr. y$, 

Cambogise pulv gr . 14' 

Misce et fiat one capsule. 
620 



OPERATIVE TECHNIC 621 

one, in clean cases no other local preparation is necessary until the patient 
is under anaesthesia. 

In infected cases, such as sloughing fibroid tumor or retained secundines, 
preparatory vaginal douching with formalin (i : iooo) may be carried out 
several times prior to the operation. When a deodorizing solution is re- 
quired, lysol (i per cent.) or a weak solution of potassium permanganate 
(i : 5000) is satisfactory. 

After the patient has been anaesthetized the vulva, vagina, anus, and the 
adjacent parts should be scrubbed with green soap and hot water, and 
rinsed with sterile water and bichloride solution (1 : 1000). 

When an intravaginal operation is to be performed that will possibly 
involve the peritoneal cavity, e.g., anterior or posterior vaginal celiotomy, 
vaginal myomectomy, or hysterectomy, it is advisable to prepare the patient 
as if a celiotomy were contemplated, for sometimes it will be, found 
requisite to switch from the vaginal to the suprapubic route, and then such 
previous abdominal preparation will stand the surgeon in good stead. 

Abdominal Sections. — The pubes and abdominal surface should be 
shaved ; no other local preparation need be given until the morning of the 
day of operation. On this day, after the bowels have been cleared out, and 
with no previous wetting of the skin, the abdominal surface, from ensiform 
to pubes, and from flank to flank, is painted with a 5 per cent, solution of 
iodine crystals in 95 per cent, alcohol. After the solution has dried the 
surface is covered with sterile gauze held in place by a binder. When the 
anaesthetic has been administered, and just before the operation is begun, the 
iodine application to the abdominal surface is repeated. 

PREPARATION OF THE OPERATOR AND ASSISTANTS 

No one should engage in an operation who has, within twenty-four hours. 
been exposed to a contagious disease or is in ill health. Those who have unavoid- 
ably or accidentally come in contact with such diseases as scarlet fever and diph- 
theria should not enter the operating room until they have had an opportunity to 
disinfect their clothing and take a full tub-bath and a shampoo. No one 
should take part in an abdominal operation whose unprotected hand has 
come in contact with pus or infectious fluid of any kind. If, during such 
exposure, the hands were protected with rubber gloves, there will be no 
risk of spreading infection provided the gloves were whole and in removing 
them the hands were not contaminated. If there is any reason to fear infec- 
tion, it is a good plan, as a rule, to allow twenty-four hours to elapse before 
another operation is undertaken, whether or not gloves were worn. Those 
engaged in surgical work should carefully avoid soiling their hands with 
discharges or excretions of any kind. In making pelvic examinations, dress- 
ing wounds, etc., the wearing of rubber gloves should be made the rule. 

The clothing worn by the operator and his assistants should be such 
that it can readily be cleansed and disinfected, and should preferably con- 
sist of muslin trousers, sleeveless shirt, and rubber-soled canvas shoes. 
Sterilization of the clothing is usually not required after laundering; but 
clothes that have become soiled with infectious fluids should be soaked in a 
disinfecting solution before sending them to the laundry. Shoes should be 
washed and redressed after each use. 



622 GYNECOLOGY 

Nurses should wear fresh linen suits and canvas shoes. The heads of 
the operator, assistants, and nurses should be covered with gauze or muslin 
caps. The hands and arms should be disinfected by scrubbing them from 
the finger-tips to the elbows with hot running water and green soap, using 
a moderately stiff nail-brush or a wash-cloth, for at least ten minutes. Dur- 
ing this preparatory scrubbing the nails should be trimmed and cleaned. 

After the preparatory scrubbing a disinfecting solution should be used — 
alcohol and bichloride solution make a suitable combination. Two minutes 
should be consumed in scrubbing the hands and arms with alcohol, and one 
minute, at least, in immersing the arms and hands in a I : iooo bichloride 
solution. If alcohol alone is used, the alcohol scrub should last three 
minutes. The time consumed in the preparation should be accurately 
timed by the clock. The hands should be dried with a sterile towel and 
dusted with sterile talcum. 

After disinfection of the hands and arms has been accomplished, the sur- 
geon should put on a sterile gown, with sleeves long enough to reach below 
the wrists. Dry, sterile gloves well dusted with sterile talcum powder 
should then be drawn over the hands. The sleeves at the wrists are 
tucked under the gauntlets of the gloves. Care should be taken to see that 
the gloves are air- and water-tight. If facilities for preparing gloves by 
the dry method are not at hand the gloves should be boiled, but the dry 
method is vastly superior. Boiled gloves may be put on more easily if they 
are first filled with sterile water. When an abdominal section is to be per- 
formed gauze masks for the nose and mouth should be worn by the operator 
and his assistants. 

PREPARATION OF DRESSINGS AND UTENSILS 

Towels, sheets, gauze pads and dressings, cigarette drains, etc., should be 
sterilized in the autoclave, and exposed to a temperature of 21 2° F., under a pres- 
sure of forty pounds, for an hour on three successive days (fractional method). 
The dressings, etc., should be wrapped singly or in packages of convenient size, 
to protect them from contamination after removal from the autoclave. 

Basins and rubber or glass drainage-tubes should be boiled for twenty 
minutes. Glass jars and hard- or soft-rubber materials that are too bulky 
or that might be injured by boiling should be sterilized by scrubbing with 
hot water and soap and then immersing them for at least one-half hour in a 
warm solution of mercury bichloride (1 : 500). 

Linen or celloidin thread should be cut into lengths of six feet, wound 
upon glass bobbins, and placed within glass ignition tubes, well stoppered 
with non-absorbent cotton, and sterilized in the autoclave by the fractional 
method. Silkworm gut should be rolled into rings (six strands to a ring), 
placed within well-stoppered glass ignition tubes, and sterilized in the auto- 
clave, or the silkworm gut may be boiled with the instruments. 

Catgut is prepared in various ways that need not be discussed at this 
point. A method that has been used with greatest success consists of first 
hardening the catgut by soaking it in a 10 per cent, solution of formalin, dry- 
ing it out thoroughly, and then submitting it to the cumol process of sterilization. 

Any method, however, that produces strong, flexible, sterile gut that 



OPERATIVE TECHNIC 623 

will not be absorbed in less than ten days will serve the purpose. Many 
of the commercial guts on the market are highly satisfactory and may be 
used with good results. The best are those in which the gut is enclosed in 
sealed glass tubes containing alcohol and chloroform. The precaution 
should be taken, however, to boil the glass tubes for five minutes before 
using them, in order to sterilize the outer surface, or, if the gut will not 
stand this boiling, the tubes should be scrubbed thoroughly with hot water 
and soap, and then immersed in a bichloride solution (i : 500) for thirty 
minutes. In gynecological work chromic gut is generally more satisfactory 
than the plain, since it has greater strength and is not absorbed so 
quickly. The smallest caliber compatible with safety should be used. Plain 
catgut of small caliber is useful for the ligation of small vessels. The 
choice of the catgut depends, however, upon the individual preference of 
the operator. 

PREPARATION OF THE OPERATING ROOM AND FURNITURE 

The ceiling, sides, and floor of the room should be of such material that they 
may be washed or scrubbed without injury. At the close of an operating day the 
room should be thoroughly aired ; the furniture should be washed with 
soap and hot water, and then thoroughly gone over with a solution of 
bichloride or formalin (1 : 1000). The floor of the room should be scrubbed 
with soap and hot water. The room should then be closed and kept so 
until the next operating day, when the furniture should be washed with a 
solution of bichloride or formalin (1 : 1000). 

PREPARATION OF WASH-WATER 

The water used for washing the hands or for making up solutions for the pur- 
pose of cleaning the room or the furniture may be taken directly from the house 
taps, provided it has been filtered and is clean. Water that is used for other pur- 
poses, e.g., for disinfecting solutions for the hands, for irrigating solutions, and 
for all general operative purposes, should be taken from steam sterilizers, or 
boiled for at least one-half hour and then allowed to cool in closed vessels. Sterile 
water or salt solution for use in the abdominal cavity should be kept in flasks of 
one liter capacity, and sterilized in the autoclave on three successive days 
for one hour. 

PREPARATION OF INSTRUMENTS 

Non-cutting instruments should be sterilized by boiling for twenty minutes in 
water containing sodium sulphate 1 per cent. The edges of knives and scissors 
are dulled by prolonged exposure to heat. Such instruments may be sterilized by 
scrubbing them thoroughly with soap and water and immersing them in an 80 
per cent, alcohol solution for thirty minutes. After operation the instruments 
should be cleaned carefully in running water, boiled, polished, oiled, when neces- 
sary, and placed in a closed cabinet. 

VENTILATION AND LIGHTING 

The operating room should be ventilated by means of a forced draft fan 
placed in one corner of the room near the ceiling; the inlets should provide 
fresh air warmed during its passage into the room. 



624 GYNECOLOGY 

For artificial illumination of the operating room an indirect method 
will be found preferable, since it obviates glare. For illumination of the 
operative field the electric bulbs may be hung directly above the table, or, 
in order to avoid shadows, they may be placed at equal intervals in the 
form of a circle. In deep pelvic work it may at times be found useful to 
have a portable light of high power that may be directed at will toward any 
desired area. Daylight, preferably from the north, is the most satisfactory 



9 9 



O 




Fig. 466. — Abdominal incisions: low paramedian, right or left lateral, high 
paramedian, high right lateral. 

form of light. It is desirable to have the windows on the north side of the 
room extend to the floor level, so as to provide good daylight for vaginal 
and plastic operations. 

THE ABDOMINAL INCISION 

Low Paramedian Celiotomy Incision. — The incision for exposure of the 
pelvis should be made slightly to the right or left of the linea alba, from a 
point below the umbilicus to the symphysis ; the fascia of the rectus muscle 
is cut; the muscle is pushed to one side, or the muscle-fibers are separated 
by blunt dissection, carefully avoiding or ligating the deep epigastric 
branches (Fig. 466). If it is desired to increase the upper limits of the 



OPERATIVE TECHNIC 



625 



incision, 

bilicus. 

directly 



this may be continued to the right or the left around the urn- 
Such an incision can be closed with more security than one made 
in the median line through the linea alba, the muscle-fibers but- 
tressing the overlapped fascia of the rectus. 

Right or Left Lateral Celiotomy Incision. — A right or a left lateral 
celiotomy incision may be made along the outer border of the rectus muscle, 
from about the upper level of the umbilicus downward (Fig. 466). The 
fascia is divided close to the linea semilunaris, and the outer border of the 




V __ 



Fig. 467. — Battle's incision: (.4) skin incision; {B) fascial incision. 

rectus muscle is retracted toward the median line. Such an incision is espe- 
cially useful when made on the right, since it affords easy access to the 
appendix and has an advantage over a gridiron incision in that it permits 
an exploration of the pelvis and upper abdomen to be made at the same 
time. In making the incision the deep epigastric vessels must be carefully 
retracted, or as is usually more practical in the average case, divided be- 
tween ligatures (Figs. 467 and 468). 

High Paramedian Celiotomy Incision. — For exposure of the viscera of 
the upper abdomen the incision is usually carried through the right rectus 
muscle, either close to the median line or along its external border, midway 
40 



626 



GYNECOLOGY 



between the costal border and the umbilicus (Fig. 466). In operations on 
the liver and hepatic flexure of the colon the incision is made along the 
external border, and may be extended above by continuing it one-half inch 
below and parallel to the costal border, as far as the ensiform. 2 

An incision close to the midline is usually selected for operations on the 
stomach, duodenum, pancreas, and transverse colon. For operations on the 
spleen the incision is made preferably through the outer border of the left 
rectus muscle. 

Transverse Suprapubic Incision. — The transverse suprapubic incision is 



4 



Jfc^ 



~?3£ r ~£f&K>jfc4Bt. 



■ 



"V 




Fig. 468. — Battle's incision. (.4) skin incision through semilunar line; 
(B) incision through anterior lamella of rectus; (b) incision through pos- 
terior lamella of rectus and peritoneum; (c) omentum showing through 
incision; (d) rectus muscle turned toward median line. 

bow-shaped, with its central point about an inch above the symphysis, and 
either extremity curving slightly upward toward the anterior-superior spine. 
It is carried through the skin and fat; the flap of skin is separated from the 
underlying tissues and turned upward, exposing the fascia of the rectus 
and the external oblique. The fascia and fibers of the rectus are dealt with 
as in the usual median incision. 

The cicatrix of a transverse suprapubic incision is hidden by the growth 

2 A number of incisions have been proposed for frank gall-bladder and gall-duct 
cases. For a description of them the original papers of Mayo-Robson, Bevan. and 
McArthur should be consulted. 



OPERATIVE TECHNIC 



627 



of the pubic hair. This incision is particularly adapted to operations for 
retroposition of the uterus in uncomplicated, clean cases. 

Mackenrodt recommended and practised a bow-shaped incision on the 
line of an arch from one anterior spine to the other. The fascia and fibers 
of the rectus and oblique muscles were divided transversely, as was also the 
peritoneum as far as the deep epigastric vessels on each side. This incision 
gives excellent exposure, but is not popular, since it possesses no advantage 
over a long right or left rectus incision. 




Fig. 469. — McBurney's incision; skin incision. 



Gridiron Incision. — Operations for removal of the vermiform appendix 
in uninfected cases may conveniently be made through a muscle-splitting 
incision, with the central point over the base of the appendix (Figs. 469 to 
472). The great advantage of such an incision is that it leaves the strength 
of the abdominal wall unimpaired. Such an incision should not be used in 
acute cases, except in the earliest stage. When a mass is palpable and pro- 
tection of the surrounding areas is desirable, the right lateral celiotomy 
incision should be preferred. If the muscle-splitting incision is selected, and 
upon opening the abdomen is found to be inadequate, it may be enlarged 
according to Weir's plan, or it 
incision made. 



may be closed and a second right rectus 



628 



GYNECOLOGY 




Fig. 470. — McBurney's incision; external oblique split. 




FlG. 471. — McBurney's incision; internal oblique split. 



OPERATIVE TECHNIC 



629 



In order to enlarge the gridiron incision Weir continues the transverse 
split of the internal oblique and transversalis muscles through the sheath of 




.-D 



FlG. 472. — McBurney's incision: caecum, ileum and appendix protruding into incision. 
{A) External oblique; {B) Internal oblique; (C) Peritoneum; (D) Appendix. 




Fig. 473. — Prone position for kidney operations. 

the rectus, cutting the anterior sheath along with the external oblique 
fascia, pulling the border of the rectus toward the midline, and then cutting the 
posterior sheath (transversalis fascia) in combination with the peritoneum. 



630 



GYNECOLOGY 



In cases of high-lying and bound-down appendices that cannot be de- 
livered through the first incision, Judd enlarges the incision through the 

external oblique aponeurosis as much as neces- 
sary, and makes a second incision through the 
internal oblique and transverse muscles i]/ 2 to 
2 inches higher than and parallel to the first. 
Kidney Incisions (Fig. 473). — For exposing 
the kidney and ureter several incisions may be 
used. For exposure of the kidney alone in the 
loin, as in nephrorrhaphy or nephrotomy, 
Kelly's incision is the most useful. For lumbar 





Fig. 474. — Kelly's incision. 

nephro-ureterectomy either 
Mayo's or Israel's incision is 
well adapted. If the kidney is 
to be removed transperito- 
neally, a straight incision 
through the outer border of the 
right rectus muscle will be 
satisfactory. In uncompli- 
cated nephrectomies, when the 
kidney is not greatly enlarged, 
the muscle-splitting incision 
of Robson is most useful. 

Kelly's Incision. — K e 1 1 y 
finds the superior lumbar tri- 
angle the most satisfactory / 
avenue for the exposure of 
the kidney, except in malig- ^ 
nant cases (Fig. 474). The 
boundaries of the triangle are 
the posterior margins of the 
oblique muscles of the ab- 
dominal wall, the quadratus 

lumborum, and the twelfth FlG - 475.— Mayo's incision. (Courtesy Surgery, Gynecology and 
• Obstetrics.) 

rib. Its floor is formed by the 

aponeurosis of the oblique muscles, and the latissimus covers it. The 

oblique incision which Kelly uses is about three inches long, extending 



OPERATIVE TECHNIC 



631 



downward and outward from the little, soft, yielding spot in the angle be- 
tween the quadratus lumborum and the rib, exposing the latissimus, which 
can be lifted up like a lid or separated in the direction of its fibers or simply 
divided transversely. The whitish area of the apex of the triangle is thus 
exposed. A pair of closed forceps is then pushed through the aponeurosis 
and withdrawn, when the golden-yellow fat pops out. The opening is 
enlarged by blunt force, 



P 



^# 




^uotocW 



V AV «V>QO'CW- 



\JJ 



giving command of the 
entire field without the 
ligation of a single 
vessel. Enlargement of 
the incision is easily ef- 
fected by further sepa- 
rating the oblique 
muscle-fibers, or by 
dividing them in a 
direction downward 
and outward. Care 
must be taken not to 
injure either the last 
dorsal or the first lum- 
bar nerve (Kelly). 

Mayo's Incision for 
Lumbar Exposure of 
the Kidney. — Begin- 
ning at a point two or 
two and a half inches 
lateral to the dorsal 
spines, near the outer 
margin of the erector 
spinse muscle, a longi- 
t u d i n a 1 incision is 
made, two to three 
inches in length, 
through the skin, su- 
perficial fascia, and pos- 
t e r i o r layer of the 

lumbodorsal fascia (vertebral aponeurosis) that covers the erector 
spinse muscle. The incision lies behind the twelfth rib, from the angle, if 
present, nearly to the head, and reaches downward to a point one-half inch 
below the angle. From this point the incision passes obliquely downward 
and forward along the anterior margin of the quadratus lumborum muscle 
to a point an inch above the crest of the ilium, and, turning, runs forward 
parallel to the iliac crest as far as is necessary (Figs. 475 and 476). 

The posterior superior lumbar triangle (Kelly) just beneath the twelfth 
rib is then exposed by cutting an opening through the external and internal 
oblique, transversalis, and latissimus dorsi muscles, exposing the trans- 
versalis fascia in its lumbar portion. This fascia is then opened freely, ex- 



.4/ 
.0. 




Fig. 476. 



Muscles of lumbar area, showing outline of Edebohls' incision 
and Mayo's incision. 



632 



GYNECOLOGY 



posing the perirenal fat. The ilioinguinal and iliohypogastric nerves are 
identified and retracted out of the operator's way, and the lower part of the 
incision completed. The twelfth rib is then cleared in its posterior portion 
upward and backward to a point near to the articulation of the rib with 
the transverse process of the twelfth dorsal vertebra, and the pleura 
pushed upward. By retracting the erector spinas muscle, on the one hand, 
and the costal margin, on the other, a wide exposure at the point of previous 
inaccessibility is effected. As a rule, the kidney can readily be drawn 
through the incision to the surface with but little traction. The incision is 
easily closed and there is little or no danger of hernia (Mayo). 

Israel's Incision. — 
Israel exposes the kidney by 
an oblique incision, begin- 
ning at the junction of the 
erector spinse with the 
twelfth rib, running for- 
ward and downward to a 
point two or three finger- 
breadths to the median side 
of the anterior superior 
spine of the ilium (Fig. 
477). This direction has 
the advantage of exposing 
the upper segment of the 
ureter. If it is desirable to 
expose this further down- 
ward toward the bladder, 
the incision is lengthened 
from its lower end down- 
ward and forward parallel 
to Poupart's ligament. To 
palpate the ureter as far as 
its insertion into the blad- 
be lengthened to the outer 
or to operate on the vesical section under good exposure the rectus may be 
incised. If this incision does not give sufficient room in difficult nephrec- 
tomies, Israel uses a second incision — a transverse, beginning two finger- 
breadths below the border of the ribs, and running anteriorly toward the 
rectus muscle at right angles. Israel's incision is especially applicable to 
nephrolithotomy and nephrectomy. 

Robson's incision is suitable for nephrotomy and for nephrectomy. It 
has the advantage of exposing the kidney by splitting the muscles in their 
course, without dividing muscle-fibers or weakening the abdominal wall, 
and without wounding vessels or nerves. Robson's operative incision is 
begun to the inner side of the anterior-superior spine of the ilium, and is 
carried backward obliquely toward the tip of the last rib (Fig. 478). The 
fibers of the external oblique and its aponeurosis are separated and retracted, 
exposing the internal oblique muscle, the muscular fibers of which are split 
on a line between the ninth costal cartilage and the posterior-superior spine 





Fig. 477. — Israel's incision. 

der, the incision mav 



Fig. 47! 

border 



ol 



Robson's incision. 

the rectus, 



OPERATIVE TECHNIC 



633 



of the ilium, in which position they are longer than in front of or behind that 
line. The fibers of the transversus are split and retracted along with the 
oblique muscle. 

A diamond-shaped space is thus formed, at the bottom of which is seen 
the transverse fascia ; this is incised, exposing the perirenal fat, and on push- 
ing through the fat, the kidney is easily reached in whatever position it may 
lie. This incision gives plenty of room, and if needful, the whole hand can 
be introduced into the circumrenal space. If it becomes necessary to expose 
the ureter, the incision may be continued obliquely downward toward Pou- 










> 



Fig. 479. — Towelling the incision, one side completed. 

part's ligament. The internal oblique will then require suture to bring the 
divided ends together. Preferably a second lower incision through the outer 
border of the rectus muscle may be made to reach the ureter (Robson). 

DIRECTIONS REGARDING ALL INCISIONS 

Whatever the site of the incision, it may be stated as a general rule that all 
incisions should be sufficiently long to expose the operative area freely. As a rule, 
the skin incision should be slightly longer than the incision through the fascia. 
After making the first stroke, which is carried just through the skin, the 
blade of the knife and the cut exposed edges of the skin may be wiped with 



634 



GYNECOLOGY 



alcohol ; the subcutaneous fat is then divided down to the underlying fascia. 
The fascia may now be cleared of fat on either side of the median line for 
about one-quarter of an inch, thus facilitating the subsequent overlapping 




Fig. 480. — Towelling the incision, both sides completed. 

and suture of the fascia. At this point towels should be clamped to the 
edges of the skin on either side of the wound (Figs. 479 and 480) ; this pre- 
vents contact with the skin throughout the subsequent steps of the opera- 




'''• 



Fig. 48] 



-Incision made: sides protected with gauze pads; self-retaining retrac- 
tor in position; myoma uteri exposed. 



tion. When the incision is cleared, the fascia is divided in the line of the 
skin incision and the underlying muscle exposed. In celiotomy incisions, as 
a rule, the muscle-fibers are not incised, but separated by blunt dissection 
down to the underlying preperitoneal fat (Fig. 481), or the neighboring 



OPERATIVE TECHNIC 



635 



border of the muscle is separated from its attachments and the muscle is 
retracted to one side (Fig. 484). In certain areas this blunt dissection must 
be assisted by an occasional nick with the knife. When the preperitoneal 
fat is exposed, it is picked up between two forceps and incised (Fig. 483). 
The fingers are introduced into the wound, and the fat is stretched or torn 



Fig. 482. 



Fig. 483. 




Fig. 482. — Separation of muscle fibers. 
Fig. 483. — Opening the peritoneum. 

so as freely to expose the peritoneum. This is caught lightly with tissue 
forceps on either side of the median line, the grasp being released and re- 
newed once or twice on either side until it is certain that the forceps holds 
nothing but peritoneum, when a small nick is made between the forceps 
points. Air at once enters the opening, and the omentum and intestines fall 



636 



GYNECOLOGY 



away from the incision. The peritoneal, and if need be the fascial and skin 
wounds, are now enlarged sufficiently to expose the operative area by cut- 
ting one after the other with heavy scissors or knife (Fig. 485), the 
intestines and omentum being protected by the first two fingers of the 
operator's left hand placed inside, with the palmar surfaces upward, along 
the line of the proposed incision. After the incision has been enlarged to a 
suitable degree, the edges should be protected with flat pads of wash-cloth 
material, which are held in position by means of retractors, or secured to 

the corresponding edges of the peritoneum with 
clamps. One of the advantages of the self-retain- 
ing retractor is that it holds these pads in a fixed 
position and prevents soiling of the subcutaneous 
fat, fascia, and muscle. 





Fig. 484. — Separation of the rectus muscle from 
its lateral attachments along the linea alba. 



Fig. 485. — Lengthening the incision. 



ISOLATION AND EXPOSURE OF THE OPERATIVE AREA 

Isolation and exposure of the operative area are secured by suitable posture 
and the introduction of gauze sponges or pads. In pelvic operations the intestines 
are made to gravitate out of the pelvis by raising the pelvis and lowering the chest 
(Trendelenburg's position) (Fig. 487). In operations involving the upper 
abdomen the position is reversed, i.e., the chest and upper abdomen are 
elevated, whereas the pelvis is lowered. In operations on the gall-bladder 
and bile-ducts the lower thorax is elevated by means of a sand-bag or an air- 
cushion, or by a special elevating platform attached to the table (Elliott's 



OPERATIVE TECHNIC 



637 



position) (Fig. 488). This brings the parts nearer to the surface, and causes 
the stomach, transverse colon, omentum, and intestines to fall away from 
the operative area. It also facilitates rotation of the left lobe of the liver 
forward and upward out of the incision. 

After the operative area has been freed of coils of intestine as far as 
possible by posture, the intestines and other adjacent viscera are gently 
held to one side and gauze wrung out of hot normal salt solution or hot 
sterile water is packed in one continuous strip about the area to be ex- 
posed, so as to keep the neighboring and encroaching viscera out of the 
way. This procedure has two objects: 
First, satisfactory exposure of the field 
of operation; and secondly, avoidance of 
contamination of the surrounding parts. 
Instead of the continuous gauze roll, 
large gauze pads to each of which a tape 
is attached may be used, the tape being 
always left outside the abdomen and 
secured with a hemostat. 

Before the protective gauze pack is 
introduced the abdominal walls should 
be relaxed thoroughly, so that the intes- 
tines need not be pushed forcibly out of 
the way. Neglect to observe this pre- 
caution is believed to be one of the causes 
of adynamic ileus. 

Before introducing the gauze pack it 
is often advisable and necessary to break 
up any adhesions that may have formed 
between the omentum and the abdom- 
inal parietes or the diseased structures in 
the operative area. The extent to which 
this separation is done before packing off 
is determined by the density of the adhe- 
sions and the probability of the release of 
pus or other infectious material. 

In pelvic operations the omentum can 
usually be freed of its attachments to the 
pelvic viscera, so that the intestine may be 
rolled up above the pelvic brim and packed away. If, however, the adhesions are 
very extensive, or apparently cover and protect collections of pus, the omentum 
may be tied off at a free point above and divided; or if a portion of the small 
intestine itself is adherent and intimately associated with the focus of pelvic 
infection, it may be left undisturbed, the surrounding coils of gut being 
displaced upwards as far as possible or simply protected with folds of gauze. 

In the case of suppurative appendicitis with tumor formation, the adhe- 
sions between the appendix and the neighboring intestine should never be 
disturbed until the adjoining areas have been thoroughly walled off. 




Fig. 



.86. — Eversion of peritoneum with 
closing sature; first method. 



638 



GYNECOLOGY 



In gall-bladder and stomach operations the same precautions should be 
observed. The surrounding areas should be carefully protected, and the 
free coils of intestine held out of the way before any extensive or dense ad- 




FiG. 487. — Trendelenburg (elevated pelvis) position. 




Fig. 4! 



-Elliott position (elevated thorax; for upper abdominal operations. 



hesions are broken up. Gauze should be placed above the right kidney, in 
the case of gall-bladder operations particularly, in order to prevent the 
collection of fluid in the right kidney fossa. 

In all cases of intestinal anastomosis or resection the involved coils of 



OPERATIVE TECHNIC 639 

intestine should be drawn outside the incision and gauze pads packed below 
and around the operative area, so that contaminating fluid will not find its 
way into the peritoneal cavity. 

At the close of an operation, before the gauze pack is removed, the oper- 
ative field should be thoroughly cleansed with sponges wrung out of salt 
solution. If drainage is to be employed, it should be put in place before the 
packs are disturbed. A careful record should be made of the gauze rolls or 
pads that were prepared for use during the operation, and the count made 
after the packs are removed should correspond absolutely to the one made 
before the operation. Only after they agree should the abdomen be closed. 

EXPLORATION OF THE ABDOMEN 

In a certain number of cases it is impossible to differentiate between neigh- 
boring and related lesions unless the abdomen is opened. If, therefore, 
every other means of differentiating between two intra-abdominal con- 
ditions have been exhausted, and if operation is plainly indicated in any 
case, an exploratory celiotomy should be advised. Every celiotomy is to a 
certain extent exploratory, for the details of diagnosis are brought out and 
confirmed, or. a mistaken diagnosis is corrected. The more skilled the surgeon 
is in diagnosis, and the more complete his methods are, the less likelihood 
there will be of error. 

It is advisable, as a matter of routine, to investigate, as far as prac- 
ticable, the condition of some of the most frequently affected abdominal 
structures after the operation for which the abdomen was opened has been 
completed. This general exploration should never be carried out if the 
field invaded by the operation is the focus of septic infection. It is only in 
clean cases that general exploration is permissible, unless there are symp- 
toms that clearly indicate a second lesion at a distance from the most urgent 
one, and the exploration should then be made as soon as the abdomen is 
opened. To be specific, in undertaking an operation for pelvic inflammatory 
disease, the appendix should be exposed at once, and if necessary removed, 
before the pelvis is invaded. If symptoms strongly suggestive of chole- 
cystitis or duodenal ulcer are present, exploration of the upper abdomen 
should be made by the hand introduced through the pelvic incision before 
the pelvis is touched, but never afterward. Furthermore, after clean intra- 
pelvic operations, when the patient is in good condition, it should be a 
routine practice to examine and inspect or palpate systematically the kid- 
neys, gall-bladder, pylorus, appendix, lower ileum, and sigmoid. In this 
way lesions will be detected and may be treated that would otherwise 
escape observation and continue to render the patient uncomfortable and 
prevent the full restoration to health which she expects will follow opera- 
tion. Among these may be mentioned chronic appendicitis, adherent 
appendix, displacements and enlargements of the kidney, adhesions that 
distort the lower ileum, caecum mobile, gall-stones, redundant or kinked sig- 
moid flexure, and midline ptosis of the stomach and transverse colon. 



640 GYNECOLOGY 

HiEMOSTASIS 

In the performance of pelvic operations haemostasis is secured with liga- 
tion, clamping and torsion of individual vessels, and compression of bleed- 
ing surfaces with hot gauze packs. The bleeding vessels in the skin 
and subcutaneous fat that have been divided in making the incision should 
be caught with forceps. The instruments may be removed after the in- 
cision is completed, the vessel being twisted until the forceps is released. 
Vessels in the preperitoneal fat, especially the deep and the superior epigastric 
vessels, should be divided between two clamps, and both cut ends ligated at once. 
Haemostasis in pelvic operations, whatever their nature, should be completed as 
the operation progresses ; the blood supply may be secured with ligatures before 
division of the various structures is accomplished, or it may be left until the parts 
have been extirpated, the vessels being clamped temporarily. Some oper- 
ators prefer one method, some another. By first clamping and then tying 
the vessels the operator is enabled to complete the extirpation of the diseased 
structures in a shorter period of time, but it is questionable whether this 
method is as safe as ligation in the course of the operation. It is good 
practice to ligate the larger vessels singly and in their course pre- 
paratory to excision. After excision has been completed, the larger trunks 
are secured a second time. If, during the course of a pelvic opera- 
tion, a vessel is accidentally punctured with a needle, a ligature is placed 
upon its proximal side in order to avoid the slight risk of embolism which 
the wounding of a vessel necessarily entails. In removing the tube of one 
side without the ovary, care should be taken to preserve the ovarian circula- 
tion, as has been described under the head of Salpingectomy (page 437). 

In performing hysterectomy and bilateral salpingectomy with conserva- 
tion of one or both ovaries, the ligation of the ovarian branch to the tube 
must be done most carefully, for otherwise the ovarian supply itself may 
be interfered with. For this reason, if the tube is healthy, it may invariably 
be conserved with the corresponding ovary, the utero-ovarian ligament and 
the inner extremity of the mesosalpinx and tube being ligated without 
interfering with the intrinsic ovarian supply. 

In perforating the broad ligament, as in the Webster-Baldy operation, a clear 
space should be selected carefully, but if a vein is accidentally torn, a clamp 
must at once be applied on both sides of the bleeding spot, and later liga- 
tures that secure the injured vessel well to each side of the ruptured area. 
Hemorrhage from an incision or a needle prick in the uterine wall is best 
controlled by figure-of-eight or mattress sutures. Hemorrhage from a tear 
in the capsule of the ovary may be controlled by the passage of a fine 
suture completely through the ovary and back to the surface of entry, the suture 
being tied so as gently to compress but not to cut the ovarian stroma. Bleeding 
points on the floor of the pelvis from vascularized adhesions or vessels in the cel- 
lular tissue, rectal wall, broad ligament, etc., if of any consequence, should be 
picked up individually with forceps and tied with fine catgut, or mattress 
or circular sutures of fine gut may be used. A gauze pack wrung out of 
very hot water and firmly applied for a few minutes will usually suffice to 
check the capillary oozing. If the operator is absolutelv certain that the 



OPERATIVE TECHNIC 641 

main vessels are properly secured, slight venous or capillary oozing may be 
disregarded so far as danger to life is concerned, but from the viewpoint of 
speedy and normal restitutio ad integrum of the tissues even this should, so 
far as possible, be checked. If the oozing is so marked as to make the 
formation of a hematocele probable, and if it cannot be controlled by liga- 
tion or pressure, particularly if the operator is pressed for time, a gauze 
pack surrounded with rubber may be used. If time allows, a little patience 
and painstaking effort will in most cases be successful. 

ADHESIONS 

Adhesions may be found between any of the intrapelvic or abdom- 
inal viscera. They vary in degree from the simple attachment of a 
tag of omentum to an inflamed ovary or tube to the most widespread coales- 
cence of intestines, omentum, pelvic viscera, and parietal peritoneum. Ad- 
hesions between the omentum and the parietal peritoneum of the anterior 
abdominal wall may usually be detected on making the peritoneal incision. 
As the peritoneum is picked up with forceps preparatory to the in- 
cision, it feels thicker and more fixed than normal. Under such circum- 
stances it is desirable to open the peritoneum at a higher point, so that an 
exact orientation may be made of the parts involved. For example, if the 
adherent structure is the gastro-colic omentum, it would be well, under cer- 
tain circumstances, to refrain from separating the adhesions, lest damage to 
the omentum would necessitate resection of a portion of the transverse colon. 

The first consideration, therefore, is to identify the areas involved. The 
separation of adhesions is usually readily effected by making gentle pres- 
sure with the gloved finger or the finger wrapped in moist gauze, supple- 
mented by the immediate ligation of bleeding points. If the adhesions are 
dense, it is better to cut than to tear them. For this purpose a very sharp 
knife is used, and the line of division is determined by making traction on 
either side of the line of adhesion. In bad cases blunt dissection is more 
likely to cause visceral injury. If the adhesions are exceedingly vascular, 
clamps or ligatures should be applied and division made between them. No 
matter how complex and hopeless the separation of adhesions seems at first 
sight, patience and gentle persistence will usually overcome them. If the 
adhesions are very extensive, it is at times unwise to separate every attach- 
ment. If the small intestines are markedly adherent to each other, no 
attempt should be made to free them all, since if this is done a recurrence is 
most likely to take place. In such cases the separation should be reserved 
for such adherent coils as are kinked or obstructed, and such as conceal or 
render inaccessible other organs that the operator desires to expose. In 
separating the uterus or adnexa from the rectum, sigmoid, or small intes- 
tines, thorough exposure to view, as well as to palpation, will avoid trouble- 
some and dangerous tears of the hollow viscera. The fingers should hug 
the uterus or adnexa closely, and the lines of natural cleavage and of less 
resistance should be sought, while the occasional use of the knife or scissors 
will open up planes of tissue and serve to prevent laceration of important 
viscera. At times, when it is evident that the separation of adhesions be- 
tween the pelvic viscera or growths and the intestines will almost certainly 
41 



642 GYNECOLOGY 

be attended by injury, the capsule or outer coat of the adherent viscus or 
tumor may be shelled of! and left attached to the bowel; the raw surface 
should be whipped over, or flaps may be made and approximated by sutures 
in such a way as to prevent compression or constriction of the bowel. In 
some cases, especially in those in which an ovarian or tubal abscess has 
previously been connected with the bowel by means of a fistulous opening, 
it will be impossible to free the adhesions without tearing the bowel. When 
the two limbs of a coil of intestine lie parallel and are intimately adherent, 
forming a partial obstruction, and there is great danger, from separating 
the adhesions, of inflicting serious injury that will require resection of bowel 
and anastomosis, a simple enteroenterostomy with clamps between the two 
coils will be the most advantageous procedure. 

WOUNDS OF THE VISCERA 

Whenever the bladder, intestine, or ureters are torn during the 
separation of adhesions or in the course of an operation the injury should 
be repaired at once. When the bowel is the seat of injury this usually 
is accomplished by the passage of two rows of continuous or inter- 
rupted linen or celloidin thread sutures, closing the opening and bringing 
healthy serous surfaces together, transversely to the axis of the gut. If the 
laceration is extensive, or if the blood supply is so greatly impaired by 
injury to the mesentery that the gut would be likely to become gangrenous, 
resection of the affected area, with end-to-end or lateral anastomosis, must 
be practised. The latter is usually to be preferred. When speed is a matter 
of importance, the Murphy button is valuable. 

When the rectum is injured low in the pelvis, with loss of tissue, and if 
the site of injury is such as to render excision and anastomosis exceedingly 
difficult, if the uterus is available, its posterior surface may be sutured into 
the rectal opening, its serous covering temporarily forming a part of the 
anterior rectal wall. If the uterus has been or must be removed, the 
stump of the cervix may be used, or the posterior vaginal wall, the bladder, 
or a flap of peritoneum. 

After repairing an injury to the rectum a test of the completeness of the 
closure should be made by injecting salt solution into the bowel. 

The ureters and the bladder may be injured during the separation of 
adhesions, but they are more often wounded during the course of an opera- 
tion requiring separation of the bladder from the neighboring uterus or the 
anterior vaginal wall. Supravaginal hysterectomy for a fibroid tumor that 
has displaced or distorted the bladder and the extensive panhysterectomy for 
cancer of the cervix especially predispose to such an accident. The wound 
is usually above the trigonum, and may readily be closed by an inner row 
of catgut and an outer row of linen or celloidin thread sutures. If the 
injury involves the trigone, the ureters must be orientated accurately before 
the sutures are passed. 

If the ureter itself is merely cut without being completely divided, and 
the structure is not bruised or lacerated, immediate repair may be effected 
by introducing interrupted sutures of fine catgut passed through the outer 
coats and coaptating the cut surfaces. If the ureter is completely divided, 



OPERATIVE TECHXIC 643 

or if it is bruised or lacerated as well as cut. several plans are available. If 
the injury is near the bladder, the proximal end of the ureter should be im- 
planted into the bladder, or the proximal end may be implanted into the 
distal end. If neither of these plans appears feasible, an anastomosis may 
be made between the ureter and the rectum. When the ureteral anasto- 
mosis threatens to be difficult, and rapid completion of the operation is 
desirable, if the kidney on the uninjured side is sound, the cut ureter should 
be doubly ligated and dropped. This causes pain for a few hours or days. 
but the kidney on the ligated side soon ceases to function and may give no 
further trouble : should it do so. the organ may be removed later by 
nephrectomy. After all forms of ureteral anastomosis the anastomotic area 
should be covered or enveloped with peritoneum or a pad of fat or omentum. 
The technic of these operations is considered on pages 492-495. 

Ligation of the Ureters. — See Post-operative Complications. Chapter 
XXXVII 1. 

TREATMENT OF DENUDED SURFACES 

The treatment of surfaces denuded as the result of the separation of 
adhesions is a difficult but most important problem in order to avoid their 
post-operative recurrence. As a rule, after every salpingectomy, salpingo- 
oophorectomy. or hysterectomy the raw surfaces may be covered by prop- 
erly disposing the peritoneal reflection of the bladder or the peritoneal sur- 
faces of the broad and round ligaments. The anterior wall of the rectum. 
the sigmoid flexure, and the omentum — all may be so disposed by sutures as 
to assist in covering raw surfaces, and thus lessening the liability to the 
formation of adhesions. A study of the technic of the various operations in 
pelvic surgery will show this peritonealization to be the final step in all. 

It would be extremely fortunate if a material were discovered that 
could be spread over raw surfaces and so prevent the formation of adhesions. 
Up to the present no satisfactory substance has been found. The most 
promising of those recommended have been cargile membrane (the dried 
serous membrane of the ox I and various oily preparations. X'one of these 
has a constant or a positive value. 

Some raw surfaces may be covered up by bringing one-half of the sur- 
face in contact with the other half or by attaching the entire surface to a 
neighboring structure,, taking care that no small pockets or openings are 
formed that would predispose to strangulation of the intestine. Raw areas 
on the intestine or mesentery may be covered with omentum or attached 
to the parietal peritoneum, provided the intestine is in such a position that 
it can functionate normally and no small openings or pockets are formed in 
which a knuckle of gut might be caught. 

A raw edge of omentum should be rolled up into the healthy surface 
of the omentum and secured by sutures. After extensive separation 
of adhesions and the exposure of considerable raw surface on the pos- 
terior aspect of the broad ligament, if hysterectomy is to be done, the 
anterior peritoneal surface of the broad ligament and bladder should be 
conserved as far as possible, so that there will be sufficient loose peritoneum 
to draw over the floor of the pelvis and the posterior surface of the base of 



644 



GYNECOLOGY 



the broad ligament. Occasionally all that one can do is to wash the raw 
surfaces thoroughly with salt solution and move the bowels shortly after 
operation in the hope that, by exciting active peristalsis, the formation of 
new adhesions may be prevented. 



CLOSING THE INCISION 

The peritoneum is closed with a running suture of fine gut, so placed as to 
evert the edges of the peritoneum (Figs. 486 and 489). This is done in an 
endeavor to avoid the formation of adhesions between the inner surface of the 
incision and the abdominal viscera. It is very important ; otherwise adhe- 
sions will form in a large proportion of cases. 

Muscle sutures may be omitted in closing incisions involving the rectus muscle, 

for if the fascia is overlapped, the separated 
fibers of the muscle will lie in apposition 
and hence a suture is unnecessary. If the 
operator prefers, he may unite the muscle 
borders with a running suture of fine catgut 
or a few fine interrupted sutures. In muscle- 
splitting incisions, notably the McBurney 
incision for removal of the appendix, the 
borders of the split muscle may be approxi- 
mated by one or two sutures. If a muscle 
is cut across its fibers, one must reunite the 
cut ends. These are approximated with 
fine gut while splint sutures of the mattress 
type are placed at some distance from the 
cut edges. 

The fascial suture is the most important. 
The general principle in suturing the fascia 
is that of overlapping. In the ordinary 
right rectus incision the superior surface 
of the fascia on the left side of the incision 
is cleared of fat, whereas the under surface 
of the fascia on the opposite side is freed 
from the underlying muscle. Sutures are 
now introduced so as to unite the superior 
surface of the fascia on one side to the under 
surface of the fascia on the other side. This may be done by interrupted or con- 
tinuous sutures, as the operator prefers (Fig. 490). A combination of inter- 
rupted sutures at one-inch intervals and a continuous suture for the entire 
length will prove very satisfactory. 

The fat layer may be disregarded except when it is abnormally thick ; it 
then should be drawn together with interrupted through-and-through 
sutures of silkworm gut. 

The skin suture should be of fine catgut. It may be used as a sub- 
cuticular or as a buttonhole stitch (Fig. 490) ; the latter is the easier to 
introduce, and gives an equally good approximation ; it permits better drain- 
age of the subcutaneous fat, but leaves a more unsightly early scar. Later 




Fig. 489. 



— Eversion of peritoneum; closing 
suture; second method. 



OPERATIVE TECHNIC 



645 



the line of incision is less likely to undergo hypertrophy or to stretch than 
after the subcuticular stitch. 

Mass suture or through-and-through suture of the incision may be used 
when rapidity of closure is the first requisite. The needle is passed through 
the skin, subcutaneous fat, fascia, muscle, and peritoneum. It is introduced 




Fig. 490. — Closing fascia, showing detail of suture for overlapping. 

about a quarter of an inch from the edge of the skin incision, passed with a 
full sweep outward through the fat, fascia, and muscle, and made to emerge 
on the under surface of the abdominal wall one-eighth inch from the edge 
of the peritoneum ; the suture is then continued in an opposite direction 
through the other side. A closure of this sort, in a majority of cases, secures 
good approximation of the borders of the wound; the point where the stitch is 



646 



GYNECOLOGY 




SWuv 



exposed upon the under peritoneal surface is sealed over in the course of a 
few hours, so that there is little risk of adhesions. Nevertheless, except 
in the most hazardous cases, when every minute counts, through-and- 
through mass sutures are inadvisable. In very stout individuals, or when 
drainage is used, or if, for any other reason, it appears desirable to make the 

incision particularly secure, the 
combination of splint sutures, em- 
bracing all the layers of the abdom- 
inal wall except the peritoneum, 
should be. used with a continuous 
suture of the peritoneum and fascia. 
The splint sutures are placed 
after closure of the peritoneum, an 
inch or more apart, and held with 
hemostats to either side of the in- 
cision ; a continuous suture of the 
fascia is then introduced, after 
which the splint sutures are tied. 
If necessary, additional interrupted 
skin sutures may be introduced. 
When drainage is used in the in- 
cision, whatever the form of suture 
selected, two through-and-through 
sutures, taking in all the coats of 
the abdominal wall, including the 
peritoneum, should be placed one 
just above and one just below the 
drain. If the drain is put 
for the purpose of controlling 
hemorrhage and is to be removed 
during the course of twenty-four 
hours, another suture may be in- 
serted, but not tied at the site of the 
drain ; this may be tied after the 
drain is taken out, completing the 
closure. 



I 




L 



Pig. 491. — Finish of buttonhole stitch. 



DRESSING THE INCISION 

After the skin suture is completed, 
the line of incision should be 
carefully dried, touched with a 5 per 
cent, solution of iodine, and sev- 
eral thicknesses of dry folded gauze applied, the surrounding skin areas 
having first been carefully cleansed. The dressing should be held in 
place by broad strips of perforated adhesive plaster, running from flank 
to flank, and covering the entire abdominal surface from above the upper 
limits of the dressing to the symphysis pubis. If the plaster is applied 
snugly, no other support is needed. To prevent it from becoming 
loose in the groins a perineal pad of sterile gauze (this is usually required) 



OPERATIVE TECHNIC 



647 



and a "T" bandage should be applied. A plan which Clark has recently 
used with success is illustrated in Fig. 493 ; this facilitates examination and 
dressing of the wound with a minimum amount of discomfort to the patient. 
When drainage has been employed, the end of the drain is transfixed with a 
safety-pin about a quarter of an inch from the skin surface, and a layer of 
gauze wrung out of 1 : 4000 bichloride solution is interposed, a straight cut 
being made in the gauze so as to facilitate this arrangement. Additional 
folds of moist bichloride gauze are now put over the end of the drain, 
and over these dry gauze and a layer of cotton. These dressings may 
be anchored in place by a few strips of adhesive plaster, and the abdo- 




Fig. 492. — Suprapubic pelvic drain. 



men should be enveloped in a Scultetus bandage for the first few days. The 
dressings are changed or reinforced as soon as they become soiled ; usually 
a daily dressing is sufficient. Later, especially when frequent dressing is 
required, side straps of adhesive plaster with tapes attached, which can be 
tied over the dressings, are most satisfactory. The ordinary clean incision that 
gives no evidence of faulty union, severe pain, rise of temperature, etc., 
need not be dressed for ten days after the operation. At that time the gauze 
and plaster should be removed, the skin cleansed with alcohol, and a fresh 
dressing applied. When the incision has been a large one, when drainage 
has been employed, and when the abdominal wall is heavy and relaxed or 
very fat, it is advisable for the patient to wear a binder for several months. 



648 



GYNECOLOGY 



For small incisions that have healed per primam, in young individuals with 
good muscular development, a special binder is not important, since the 
ordinary corset answers all the necessary requirements. 

SPONGES AND PADS USED IN ABDOMINAL SURGERY 

In abdominal and pelvic surgery sponges and pads are used for three pur- 
poses : (i) To remove blood (sponging) and detritus from the field of opera- 
tion; (2) to pack off the intestines from the general peritoneal cavity; and 
(3) to protect the edges of the incision. For the first purpose marine sponges 
would be preferable if their physical properties alone were considered, but be- 
cause of the difficulty in sterilizing them and the fact that they are expensive, their 
use has been generally abandoned. Nevertheless, they are still occasionally seen 




t» 



/; 




Fig. 493. — Abdominal dressing applied. 

in operating rooms, and for ordinary sponging they are much superior to gauze 
pads. Gauze sponges are made of folded squares of gauze, the rough and 
selvedge edges being turned in, and sometimes additionally secured by 
stitching. Several sizes are usually available, and to the larger ones tapes 
may be attached so that when they are placed within the pelvic or abdom- 
inal cavity for walling-ofl purposes the tapes are left hanging outside and 
secured with hemostats. Gauze in the form of pads or sponges, however, 
should be used only exceptionally for this purpose. The routine packing-oft 
and extraperitonealization should be done with a roll of gauze with edges 
folded in, the dimensions of the roll for the usual intrapelvic work being 
1 by 3 feet. For appendix, gall-bladder, and kidney operations a roll six 
inches in width may be preferred. If one roll is not sufficient, a second or a 
third may be used, the end of each strip being left to project from a suitable 



OPERATIVE TECHNIC 649 

part of the incision and being caught with a hemostat. Gauze pads or 
sponges should be packed in bundles of a fixed number and a single variety; 
rolls of gauze should be wrapped separately in muslin covers ; the number 
of gauze pads, sponges, and rolls used should be carefully recorded. When 
rolls of gauze are employed for packing-off no pads should be placed inside 
the abdomen, except under unusual and urgent circumstances. All gauze 
sponges, pads, or rolls used during an abdominal operation, either internally 
or externally, should be counted and recorded before the operation is begun 
and after it is completed ; the two counts must agree before the incision is 
closed. All gauze used within the peritoneal cavity should be moist, i.e., it 
should have been wrung out of hot sterile water or hot normal salt solution. 
By this means irritation of the peritoneal surface is reduced to a minimum. 

ANESTHESIA 

One of the most important details in connection with an operation is that of 
rendering the patient insensible to the procedure, with a minimum of shock to 
the nervous system and the least possible depression of the vital functions. 

Anaesthesia is produced in various ways ; the most customary method is 
by the inhalation of nitrous oxide, oxygen, and ether. Ether and chloro- 
form have been very popular in the past, ether being generally preferred be- 
cause of the fact that it is less dangerous, but chloroform has, nevertheless, 
many advocates. During recent years nitrous oxide has been very generally 
employed previous to the ether, narcosis being induced by the nitrous oxide 
and continued with the ether. At present nitrous oxide and oxygen are em- 
ployed extensively for operations of short duration ; for prolonged opera- 
tions nitrous oxide, oxygen, and ether constitute the most efficacious and 
the safest combination. 

Ether. — For routine administration ether is the safest of all anaesthetics. 
It has, however, certain disadvantages and dangers. The after-effects of 
ether consist of nausea, vomiting, and extreme thirst. Its use may light up 
an old tuberculous lesion ; it may produce pneumonia or nephritis, or may 
aggravate an old renal condition. In fat, thick-necked people and in asth- 
matics, it may be impossible to administer ether without causing strangula- 
tion. By reason of its effect on the body heat or on the excretory func- 
tions, serious shock or profound toxaemias may be increased by the use of 
ether. Nevertheless, for the average surgical case, when carefully and 
properly administered, preceded or not by nitrous oxide, it is the least harm- 
ful and the most satisfactory of all anaesthetics. 

Chloroform. — Chloroform is more rapid in its action than ether, and the 
anaesthetization is effected with less struggling and less general disturb- 
ance. It is not so irritating to the mucous membranes of the respiratory 
tract, and probably irritates the excretory cells of the kidney less than 
ether does. Chloroform is much more dangerous, however, since it is de- 
pressing to the circulation ; it may, with very little or no warning, cause 
cardiac arrest and death ; in a small proportion of cases also, when anaes- 
thesia is prolonged, it may cause acute yellow atrophy of the liver. Its dis- 
advantages appear, therefore, to exceed its advantages, and for major pelvic 
or gynecologic operations chloroform anaesthesia has fallen into disfavor. 



650 GYNECOLOGY 

Nitrous Oxide and Oxygen. — The administration of nitrous oxide, when 
combined with oxygen, may be continued almost indefinitely. This has 
become a favorite method of anaesthesia for brief operations. Pelvic opera- 
tions, in which perfect relaxation of the abdominal wall is required, are not 
adapted to the use of nitrous-oxide-oxygen anaesthesia, but in abdominal 
operations in which absolute relaxation is not required this form of anaes- 
thesia may be employed with satisfaction. The anaesthesia should be pre- 
ceded for a half hour or so by the exhibition of morphine (gr. }i) and 
atropin (gr. 1/150). This helps to quiet the patient and promotes muscular 
relaxation. The nitrous oxide and oxygen are administered by means of a 
special apparatus that permits a mixture of any relative proportion desired. 
Nitrous oxide has the disadvantage of raising the blood-pressure, so that in 
patients with high blood-pressure or cardiac disease it is contraindicated or 
must be used with extreme caution, and with a large admixture of oxygen. 

Nitrous Oxide, Oxygen, and Ether. — By combining nitrous oxide, oxy- 
gen, and ether an anaesthesia may be effected that will meet nearly all 
requirements. The anaesthesia may be quickly induced with the nitrous 
oxide, continued in combination with oxygen for brief operations, when 
deep intra-abdominal or pelvic work is not being done, or supplemented 
with ether when the operation is of longer duration or demands more 
complete relaxation. 

Anaesthesia by Combined General and Local Methods. — Crile believes 
that when an operation is performed under general anaesthesia continual 
shocks are sustained by the central nervous system from the impressions of 
trauma that are conveyed there by the sensory nerves in the operative 
region. These subconscious impressions, he asserts, are largely responsible 
for what is known as surgical shock. He seeks to eliminate these impres- 
sions by his method of " Anoci Association " (see Chapter XXXV, page 617). 

Ethyl Chloride. — Ethyl chloride by inhalation is suitable only for very 
brief anaesthesia. It is not generally applicable to gynecologic operations, 
although it may be used for minor surgical procedures, as, for example, the 
incision of a vulvovaginal abscess. When used longer than momentarily, 
it becomes a dangerous and harmful anaesthetic, since it produces at times a 
spasm of the respiratory muscles. 

Local Anaesthesia. — Local anaesthesia is the method of producing anal- 
gesia by the application of an anaesthetic solution either directly to a body 
surface or by injecting it into the underlying substance. The range of 
usefulness of local analgesia in gynecologic and pelvic surgery is generally 
limited to minor operations upon the external genitalia, as, e.g., the removal 
of a urethral caruncle, and to celiotomies in which little more than an ab- 
dominal incision need be made, as when the operation is performed for 
non-adherent ovarian cyst, localized collection of pus, and the like. The 
field of usefulness of local anaesthesia may, by painstaking technic and 
patience, be extended to herniotomy and anterior vaginal hysterotomy, but 
in the absence of distinct contraindication to general anaesthesia, its use is 
not to be recommended. 

Solutions for Producing Local Anaesthesia — Eucaine, Cocaine. — Local 
anaesthesia of the bladder and urethra may be induced by the injection, 



OPERATIVE TECHNIC 651 

into the bladder, of a 4 per cent, solution of eucaine or cocaine. The solu- 
tion should be applied directly to the trigone through a Kelly cystoscope, 
or injected by means of a catheter or a syringe with a long curved beak. 
A few drops also may be instilled into the urethra as the instrument 
is withdrawn. Local anaesthesia of this type may occasionally be re- 
quired in making cystoscopic examinations, particularly in performing 
catheterization of the ureters in highly nervous and neurotic individuals 
or in those with exceedingly painful affections of the urethra or blad- 
der. Anesthetization of the external urinary meatus is effected by appli- 
cation, directly to the mucosa, of a pledget of cotton wet with a 10 per 
cent, solution of cocaine. Cocaine is the most effectual local anaesthetic. 
When the anaesthetic solution is to be injected, novocaine is much to be 
preferred to cocaine. Novocaine in a ^4 of a 1 per cent, solution, combined 
with suprarenal extract, is comparatively without danger, and may be used 
freely. The tissues must be infiltrated with the solution. Novocaine may 
be sterilized without undergoing decomposition. 

Quinine hydrobromide and urea may be used in a ^ to ^ of a 1 per 
cent, solution in conjunction with local novocaine anaesthesia, as in the 
method of anoci association of Crile, or in certain operations in conjunction 
with general anaesthesia. Its use must be accompanied by massive infiltra- 
tion of the tissues at a distance from the seat of operation. Its anaesthetic 
effect does not begin immediately, but usually within fifteen minutes, and 
continues for from thirty-six to forty-eight hours. It is, therefore, most 
useful in operations associated with marked post-operative pain, as, e.g., 
perineal and anal operations. 

Technic of Producing Local Anaesthesia by the Injection of Novocaine — 
Celiotomy Incision. — With a fine needle a drop or two of the solution 
should be injected into the substance of the skin (intracutaneously), not 
beneath it, in the projected line of incision. Into the periphery of the little 
welt thus raised another injection should be made, and still another, until 
the entire length of the contemplated incision has been treated. Division 
of the skin and subcutaneous fat is now painless ; the fascia and the perito- 
neum must be infiltrated in the same manner as the skin. A razor-edged knife 
should be used, and the incisions should be confined strictly to the infiltrated area. 
After the peritoneal cavity is opened the abdominal wall may be infiltrated 
with quinine and urea (}i per cent, solution) at a point about an inch from 
the incision. 

Vulvar or Vaginal Incisions. — The same procedure is followed as in the 
case of celiotomy incisions. The solution is injected into the substance of 
the skin or the mucosa. After dividing the anaesthetized skin, if the exposed 
subcutaneous tisues are sensitive, they must be infiltrated in turn. In 
vaginal, as in abdominal celiotomy, the peritoneum must be dealt with sepa- 
rately. After perineal operations infiltration of the tissues with quinine and 
urea (% per cent, solution) may be made at the periphery of the operative 
area and about an inch from it. 

Cervix Operation or Hysterotomy. — The cervix may be anaesthetized 
for performing dilatation by injecting a novocaine solution into its sub- 
stance at numerous points in the periphery of the canal. . In anterior hys- 



652 GYNECOLOGY 

terotomy a line of infiltration on the anterior lip is begun at its lower 
margin, and continued to the reflection of the vaginal mucosa. A transverse 
line of infiltration is now made, and the anterior vaginal attachment is 
divided. The bladder is next pushed up, exposing the anterior surface of the 
cervix and the lower uterine segment ; the anterior wall of the uterus is then 
infiltrated, and the anterior hysterotomy incision is made. 

Local Anaesthesia by Freezing with Ethyl Chloride. — Local anaesthesia 
by freezing with ethyl chloride may be used for such minor operations as 
opening a vulvovaginal abscess or removing venereal warts. The tube 
should be held from 12 to 18 inches from the area to be frozen, and the 
spray run up and down the line of the proposed incision until the area be- 
comes white. Evaporation will be increased by fanning the area. Deep 
freezing is inadvisable for fear of causing sloughing of the tissue. 

Spinal Anaesthesia in Pelvic Surgery. — The administration of a general 
anaesthetic may be undesirable or dangerous in: (1) Cardiac , pulmonary, 
or renal lesions of such a nature that general anaesthesia will embarrass or 
injure the circulatory, respiratory, or urinary symptoms. (2) Toxic states 
in which the excretory organs have already been taxed to their utmost, and 
in which the addition of another poison will mean excretory insufficiency. 

When operation is imperative, or is highly desirable in patients who are 
unfavorable subjects for general anaesthesia, we turn naturally to local 
anaesthesia — i.e., the concentration and limitation of the anaesthetic sub- 
stance, whatever it may be, to the operative area, so that analgesia is pro- 
duced, without any general influence being induced. 

Without going into a discussion of local anaesthesia, it may be said in a 
general way that for pelvic operations in which full relaxation of the ab- 
dominal wall is required, infiltration of the operative area with anaesthetic 
solutions is unsatisfactory. This leads us more or less logically to spinal 
anaesthesia, which is really a form of local anaesthesia ; by this method, how- 
ever, the anaesthetic selected is applied directly to the root of the nerves, 
instead of to their peripheral branches. It would seem, a priori, that a 
much smaller quantity of any drug would be required if the anaesthesia 
were localized at such a point, and that the effects would be more 
strongly marked. 

In a successful case of spinal anaesthesia, the anaesthetic drug becomes 
mixed with the spinal fluid, bathing the motor and sensory roots of the 
cord at and below an elected point, inducing motor and sensory paralysis of 
the areas supplied by those nerve-roots ; in other words, an inhibition of 
pain in the operative area and full muscular relaxation. 

The patient is prepared for the injection of the anaesthetic by a dose of 
morphine (gr. %) and scopolamine (gr. 1/150). Usually one dose is suffi- 
cient, but if the patient is extremely nervous, the dose may be repeated. 
In some cases bromide or veronal the evening before operation will be ad- 
visable. If the preliminary injections are given at least an hour before the 
time set for operation ; if the patient's ears are lightly plugged with cotton ; 
if a bandage is placed over the eyes, and she is kept in a quiet room, she is 
usually in a drowsy condition or is actually asleep when the time for 
operation arrives. 



OPERATIVE TECHNIC 653 

The after-condition of the patient usually is ideal. A majority complain 
of no discomfort whatever. As a rule, there is no nausea. Occasionally a 
patient will complain of headache, but it is scarcely ever of sufficient severity 
or duration to become a serious matter. The post-operative suffering is less 
than after the use of ether or chloroform, and probably a trifle more than 
after nitrous oxide anaesthesia. 

The best technic is that elaborated by Babcock. The solution em- 
ployed consists of stovain (0.08 gm. ), to which is added a small amount 
of lactic acid (0.04 c.c.) for the purpose of holding the drug in suspension 
in the alkaline spinal fluid, and a small quantity of alcohol (0.2 c.c. ; water, 
1.8 c.c), to make the solution of lower specific gravity than the spinal fluid, 
which is constantly between 1.00055 an< ^ 1.00065. Another solution of a 
specific gravity greater than that of the spinal fluid is composed of stovain (0.08 
gm.). lactic acid (0.04 c.c), milk-sugar (0.10 gm.), and water (2 c.c). 

The first and lighter solution rises in the spinal fluid ; the second is 
heavier, and sinks, so that extension of the analgesia above the point of 
injection, or limitation to the areas below, may be secured by selecting the 
appropriate solution and by elevating the head or the pelvis of the patient. 

The spinal cord ends at about the level of the disk, between the first and 
second lumbar vertebrae ; below this is the cauda equina. The second lum- 
bar interspace is a favorite site for injecting the spinal anaesthetic when 
it is desirable to secure a loss of pain sense in the perineum, external 
genitalia, and lower abdominal wall. If the upper abdomen is to be 
invaded or the incision is to reach as far as the umbilicus, the injection 
must be made in the first lumbar interspace. The technic is as follows : 

The patient is seated upon the side of the operating table with the legs 
hanging over ; the arms are folded over the lower abdomen ; the head is bent 
forward, and the back is arched. The skin surface is disinfected by the 
application of iodine and alcohol. The fourth lumbar interspace is located 
by so placing a towel that its edge runs across the line of the posterior iliac 
crests. This marks the fourth lumbar spine or the fourth lumbar inter- 
space. The second or the first lumbar interspace is now located, and the 
skin is marked at the lower border of the spinous process above it. After 
the mark has been made, the patient must be warned not to move. The 
needle is next thrust through the skin, about 2 mm. to one side of the 
median line, and then pushed toward the spinal canal, being held perpen- 
dicularly to the surface. It is carried forward until the resistance of the 
ligamentum subflavum is felt, when the mandrin is withdrawn. As soon as 
the resistance of the ligament is overcome, the needle is pushed cautiously 
onward, a few millimeters at a time, until the slight resistance of the dura 
is felt. Puncture is often accompanied by a palpable snap, after which 
spinal fluid drops from the needle. The needle is carefully rotated, to make 
sure that the bevelled point is entirely through the membrane. The syringe, 
filled with the anaesthetic solution, is attached to the needle, and about 1 c.c 
of the spinal fluid is drawn into the barrel. The mixture of spinal fluid and 
stovain solution is now steadily and somewhat rapidly injected, the needle 
is quickly withdrawn, and the patient is immediately placed in the recum- 
bent posture, with the head slightly raised. Analgesia is usually complete 



654 GYNECOLOGY 

by the time the operative area is prepared, which generally consumes from 
three to five minutes. 

If celiotomy is to be performed, the injection must be made in the first 
lumbar interspace. Injections in the second lumbar interspace occasionally 
produced analgesia as high as the umbilicus, but this is the exception, 
rather than the rule. 

The dose of the stovain solution is determined by the age and weight of the 
patient. The determination of the dose of stovain is one of the difficult problems 
connected with spinal anaesthesia. Even though the anaesthetic solution is 
composed after a set formula, its strength varies, either because the chemi- 
cal composition of the drug itself varies, or because its activity has been 
modified by sterilization. In a clinic where spinal anaesthesia is used con- 
stantly each new lot of anaesthetic ampoules must be tested in order to deter- 
mine the maximum and the minimum dose. The ampules as prepared for 
use contain 8 cgm. of stovain. The largest amount used in a series of gyne- 
cological operations was 6 cgm., but in most cases it was 4.5 and 5, or 5.5 cgm. 

No preliminary dose of morphine and scopolamine is given in the young. 
In those over thirty the average dose of morphine is 1/6 grain, and of scopo- 
lamine 1/150 grain. In some patients this has no appreciable effect, and 
the dose of one or both drugs may be repeated. This is determined by the 
condition of the patient (pulse, respiratory tract, pupils, etc.), and whether 
she is drowsy and inclined to sleep, or is wide-awake and nervous. It is an 
important part of spinal anaesthesia, therefore, to determine just how much 
morphine, scopolamine, and stovain are needed, for if too small a dose is 
given, anaesthesia will fail, and if too large a dose is administered the patient 
will be placed in great danger. 

Emphasis must be laid upon the necessity of immediately lowering the 
patient from the sitting position as soon as the injection is given. This. 
as is commonly the case, obtains particularly when a solution of 
lower specific gravity than the spinal fluid is used. If, under such circum- 
stances, the patient is allowed to sit up, or if she is permitted to lie down 
with the shoulders and head higher than the pelvis, the anaesthetic solu- 
tion will rise in the spinal canal and influence the higher nerve-roots. It 
should be remembered that in cleansing the syringe and the needle, alcohol 
should not be used, for it tends to diminish the specific gravity of the injec- 
tion, and may lead to a rapid diffusion. upward of the anaesthetic solution. 

Deaths on the operating table from spinal anaesthesia occur more fre- 
quently than in ether, chloroform, or nitrous oxide anaesthesia. Spinal 
anaesthesia is especially dangerous in patients with low pulse pressure. 
Not only the record of these accidents, but also the care that must be taken 
to guard against them, bears evidence of the dangers attending this method, 
and how constantly those who use it must be on their guard. 

Sudden death also occurs, but not so frequently, during the course of general 
inhalation narcosis. The greater risk in spinal anaesthesia is readily understood. 
If a patient under inhalation anaesthesia shows toxic symptoms, the anaesthetic 
can be withdrawn, whereas under spinal anaesthesia if toxic symptoms ap- 
pear, all that we can do is to tide the patient over until the effect of the 
anaesthetic has worn off. 



OPERATIVE TECHNIC 655 

Nevertheless, in contrasting the mortality of spinal anaesthesia with that 
of ether and chloroform, one must not lose sight of the fact that post- 
operative morbidity and the number of deaths from pneumonia, kidney 
insufficiency, etc., are greater after ether or chloroform anaesthesia than 
after spinal anaesthesia. Post-operative deaths and post-operative morbidity 
as the result of the administration of ether are undoubtedly much greater 
than is generally supposed. Gellhorn, in a recent paper on Spinal Anaes- 
thesia, says : " There are no statistics in existence which give a true picture 
of the alleged harmlessness of the open ether-inhalation narcosis. The 
exact number of fatalities due to ether will never be known, nor has the 
role of ether in the causation of post-operative complications which injure 
life and health of the patient ever been exhaustively considered. Few men 
have the courage to publish their failures, and the medical journals, as 
Sellheim remarks, serve as a medium for recounting accidental success 
rather than the reverse." 

MULTIPLE OPERATIONS 

It is frequently desirable, or even necessary, to perform a number 
of operations at one time. Thus, not uncommonly, a dilatation of the 
cervix, curettement, trachelorrhaphy, or trachelectomy, anterior and pos- 
terior colporrhaphy, and a round-ligament suspension of some variety are 
performed at the one operation. Very often, in addition to the plastic 
operations mentioned, the sphincter ani may be stretched, a fissure incised 
or curetted, or hemorrhoids removed. After the abdominal cavity is 
opened it may be found desirable to remove a tube, an ovary, or the appen- 
dix; there may be intestinal adhesions to be divided (Lane's kink) and even 
gall-stones to remove. To what extent these multiple operations should be 
carried depends upon the condition of the patient, the urgency with which 
each of them is demanded, and the skill and speed of the operator. When 
it is inadvisable to correct all. the abnormalities existing, those giving rise 
to the most pressing symptoms should be selected. If, by careful examina- 
tion, the operator has acquainted himself with the amount of surgery that 
needs to be done, he can usually so modify or hasten his operative pro- 
cedures as to accomplish them all without detriment to the patient. Thus, 
if the examination under ether just previous to operation has shown that, 
in addition to plastic operations, the patient requires an intrapelvic opera- 
tion of considerable magnitude, the simplest and most rapid methods for the 
plastic work should be adopted. This possibility means, in a few cases, a 
less complete restoration of the parts than if undivided attention had been 
given to the plastic work, and yet it will be vastly better than to neglect 
this aspect of the case entirely. Familiarity of the operator with his sur- 
roundings and assistants will be conducive to speed, and the opposite, of 
course, is true. It is unwise, when the abdomen is opened for other purposes, 
invariably to remove the appendix, regardless of its condition and of that of 
the patient. Gall-stones, if quiescent, should not be removed if the addi- 
tional time under anaesthesia required would be of detriment to the patient. 
It is better deliberately to plan two operations on the same patient than to 
jeopardize her life by attempting to do too much at one time. 



656 GYNECOLOGY 

OPERATIONS DURING PREGNANCY 

It need not be stated that operations should, if possible, be avoided during 
pregnancy. Nevertheless, there are certain diseases that demand operation as 
soon as they are discovered, and other conditions are encountered that may re- 
quire operation if pregnancy is to continue or to terminate successfully. In the 
first class are malignant growths and acute intra-abdominal or pelvic disorders. 
Among them may be mentioned carcinoma of the cervix, acute appendicitis, tor- 
sion or rupture of an ovarian cyst, or torsion of a pedunculated myoma. In this 
condition pregnancy does not constitute a contraindication to operation ; indeed, 
pregnancy makes the operation even more imperative. The exact procedure in 
such cases will depend upon the month of pregnancy. If the child is viable, 
Csesarean section should precede a hysterectomy for carcinoma. If the 
woman is in the last month of pregnancy, a small muscle-splitting incision may 
be successful in exposing and permitting removal of a clean appendix, and the 
woman may be allowed to go to term ; if, however, a larger median or 
muscle-splitting incision is required, Caesarean section is advisable. Ovari- 
otomy for twisted or ruptured ovarian cyst at or near term should be fol- 
lowed by Caesarean section. In the earlier months both operations may 
be undertaken with the least possible disturbance of the uterus, and the 
administration of bromides and morphine should constitute a part of the 
post-operative treatment. The most difficult cases in which to reach a 
decision are those of suppurative appendicitis with spreading peritonitis, in 
which drainage must be instituted, and in which Caesarean section adds 
decidedly to the risk of sepsis. This is really a problem of obstetrics. 
DeLee declares that a mild attack of appendicitis should always indicate an 
operation within the first five months of pregnancy. Only perforating cases 
should be operated on within the last four months, and then as soon as the 
condition is diagnosed. In cases of doubt, operation is the safer course. 
Every effort should be made to prevent premature labor. Should it, how- 
ever, set in, it should be allowed to run as natural a course as possible. If 
abortion is impending at the time of operation the uterus should first be 
emptied and then drainage of the abdomen carried out. DeLee believes that 
the question of a Porro Caesarean section at the time of operation on the 
appendix must be considered. 

The plan of Gerster should be borne in mind. This observer first re- 
moves the appendix and packs the diseased area or abscessed cavity with 
gauze, over which he tightly closes and seals the abdominal incision with 
collodion. The patient is then delivered in the ordinary way, and after labor 
is completed, the sutures are removed and drainage instituted. 

Another problem is presented by the adherent and pregnant, retroverted 
and retroflexed uterus, or by a pregnant uterus that is securely anchored 
to the anterior abdominal wall. In the first case it is best to treat the patient 
expectantly, for the adhesions sometimes stretch as the uterus enlarges. 
The outlook is improved by the regular use of the knee-chest position (five 
minutes), followed by the Sims' position for twenty minutes three times a 
day. Although an operation could be performed and the uterus restored to 
its normal position, miscarriage is very apt to follow, and a recent opera- 



OPERATIVE TECHNIC 657 

tion on the uterine ligaments would increase the difficulties of handling an 
abortion. If abortion occurs while the expectant plan is being pursued, the 
uterus can be cleaned out, if need be, without danger, and an operation to 
correct the malposition carried out at a later date. When the pregnancy 
takes place in a uterus that is fixed to the abdominal wall, the patient should 
be carefully observed — in a certain proportion of cases the attachment will 
stretch and the pregnancy go on. If abortion occurs, the case should be 
handled secundum artem; later an operation for the release of the uterus 
should be advised. If the case progresses to term, any dystocia should be 
promptly met with Csesarean section or other suitable operative procedure. 

DRAINAGE 

Drainage after intraperitoneal operations is employed much less fre- 
quently than formerly. This is due partly to the improved technic and 
to the selection of cases at a more favorable stage for operation. It is 
also partly due to the disadvantages incident to drainage, viz., a more pro- 
longed convalescence, repeated dressing of the wound, which may be pain- 
ful, and faulty healing of the incision, predisposing to hernia. 

The first drains were used for the purpose of removing what was believed 
to be septic fluid from the site of operation. This is the original and more 
common idea in the use of a drain following operation. In addition to being 
useful for the purpose of removing infectious products and directing the 
flow of toxic fluids externally, thus preventing their absorption by the peri- 
toneum, a drain also serves the purpose of what may be called a protective pack ; 
in other words, by virtue of the adhesions that form about the drainage mate- 
rial within six or eight hours, the drain effectually shuts off the healthy 
peritoneal cavity from the operative or infected region. There should, 
therefore, be a distinction between a drain and a protective pack. Drainage, 
in the true sense of the word, may be maintained for some time from an 
encapsulated abscess or from a hollow viscus, such as the gall-bladder, but in 
any other position after a short period a drain becomes a protective pack. 
It serves, therefore, no longer as a drain for anything more than the fluids 
that are thrown off by the surface immediately in contact with it. As it is 
impossible, for this reason, to drain the peritoneal cavity for any length of 
time, all drainage after a brief period, becomes a protective pack. It is true, 
however, that during this short interval drains may serve their purpose of 
removing toxic fluids and preventing their accumulation in the peritoneal cavity. 

The absorption of toxic products from the peritoneal cavity has been 
shown by a number of investigators to be most active in the upper 
part, toward the diaphragmatic area. The peritoneum possesses naturally 
a considerable amount of resistance to infection, and this resistance is 
enhanced by the omentum, which quickly adheres to and surrounds 
inflamed and infected areas, and helps to destroy infectious material 
or to neutralize it, by throwing out large numbers of white blood-corpuscles, 
which have a phagocytic action and encapsulate or destroy bacteria. Since, 
as has been stated, the upper part of the peritoneal cavity is the most active 
area of absorption, and since the use of drains in an endeavor to drain the 
entire peritoneal cavity is no longer considered reasonable, postural drain- 
42 



658 GYNECOLOGY 

age is becoming the common method of dealing with intraperitoneal infec- 
tions ; in other words, although we cannot drain the entire peritoneal cavity 
by means of drainage-tubes of any variety or in any position for any length 
of time, by elevating the trunk of the patient intraperitoneal fluids may be 
made to gravitate toward the pelvis, where absorption of toxic products 
will be at a minimum, where, from the anatomy of the abdominal cavity 
septic products are most likely to be encapsulated, and where they will 
interfere less with the functions of digestion and assimilation. If, then, in 
combination with posture, a drain is placed at a dependent point, actual 
drainage will occur during the first six or eight hours, and thereafter a drain 
will serve the purpose of a protective pack. In many cases this is all that is 
required to turn the tide of battle between the toxic products of the infec- 
tion and the vital resistance of the patient in favor of the latter. At the 
present time drainage is rarely used except in acute conditions of the pelvis 
or the abdomen. 

As it is a well-established practice at the present day to avoid operation 
during the acute stage of gonorrhoeal and other forms of pelvic peritonitis, 
and as operation is not performed in the presence of puerperal infection, 
except when a rapidly spreading general peritonitis or a localized collection 
of pus is present, drainage will be demanded only in cases of spreading 
peritonitis caused by perforation of the appendix, a duodenal ulcer, or 
similar conditions. In a spreading peritonitis, whatever the cause, the 
operation must be performed rapidly under that form of anaesthesia which 
will produce the least depression and lowering of the vital resistance. The 
infected focus should be removed with as little disturbance and manipu- 
lation of the surrounding parts as possible. One or two drains should be 
placed in the most dependent part of the abdomen or pelvis, and the patient 
placed in the sitting position. In the course of the ordinary pelvic opera- 
tions drainage need be used only in exceptional cases. Such cases may be. 
divided into three groups, as follows : 

(i) When the small intestine, the rectum, or the sigmoid has been in- 
jured in the separation of adhesions and there is doubt as to the security of 
the sutures closing the rent. 

(2) When a large amount of exudate or a considerable portion of an 
abscess sac must be left behind. 

(3) To favor hsemostasis and to provide free exit in case of extensive oozing. 
In the case of intestinal injury the greatest care should be observed to 

render the intestinal sutures absolutely secure, in which case, of course, a 
drain will be unnecessary. If a drain is used, it should be so disposed that 
it does not come in contact with the row of sutures, otherwise the drain may 
actually interfere with perfect union. 

The second group of cases is very exceptional, but may be found in 
puerperal or post-abortal cases of pelvic inflammatory disease. Under such 
circumstances the broad ligament is often markedly thickened and infil- 
trated, and the raw surfaces exposed cannot be satisfactorily covered by 
peritoneum. As such surfaces will necessarily " weep " and discharge 
septic fluid into the pelvis, a drain or a protective pack is introduced to 
carry this fluid away externally, so that it neither accumulates in the pelvis, 



OPERATIVE TECHNIC 659 

where it might set up peritonitis, nor is absorbed in the general circulation., 
where it might produce a toxaemia. 

Whenever practicable, pelvic drainage should be conducted through 
Douglas' pouch. The opening between the vagina and Douglas' sac may be 
made by having an assistant pass a pair of long curved artery-forceps to the 
posterior vaginal cul-de-sac. The blades are then separated laterally for 
about an inch, and the operator makes an incision directly between them. 
One end of the rubber drainage-tube with a gauze wick is then pulled into 
the vagina with the aid of forceps. In some cases drainage through the 
posterior vaginal incision will not be so feasible as drainage immediately 
above the symphysis. Fig. 492. This will be true when the surfaces to be 
drained or excluded are high, also when the drain is used for the control of 
hemorrhage and when haste is necessary. Under such circumstances rub- 
ber tubing with gauze wicks should be used, or the gauze should be sur- 
rounded with rubber-dam, so as to prevent the formation of adhesions between 
the drain and the surrounding intestines, and thus facilitate removal of the 
gauze. Care should be taken that the incision is not closed tightly about the 
point of exit of the drain. 

In acute appendicitis with abscess or spreading peritonitis, a rubber tube 
with a gauze wick should be passed to the bottom of Douglas' pouch, and 
another one to the most involved area in the right iliac fossa. It may be 
advantageous to bring this drain out through a stab wound in the loin, 
directly above the crest of the ilium, and an inch and a half behind the 
anterior spine, especially when the damaged area lies to the right of the 
caecum or beneath it. 

Gall-bladder and Gall-duct. — It is always advisable to drain the gall-bladder 
after performing cholelithotomy. This should be done by fastening a piece 
of rubber tubing, about the caliber of a lead pencil, in the center of the gall- 
bladder incision. The tube should be fixed and the remainder of the in- 
cision into the gall-bladder closed with catgut sutures. A circular suture 
of catgut is now placed around the gall-bladder about an inch below its 
summit, and the gall-bladder inverted as the suture is tied. This prevents 
leakage, and when the rubber tube is removed, serous surfaces will lie in 
apposition and union rapidly take place. It is not necessary and quite un- 
desirable to attach the gall-bladder to the peritoneum of the abdominal in- 
cision. (The tube is usually removed about the tenth day, when the catgut 
sutures are absorbed.) 

If the gall-bladder is infected or the surrounding parts have become soiled, 
a cigarette drain should be placed in the peritoneal cavity below 
the gall-bladder. 

After simple cholcdochotomy the incision in the common duct may be 
closed, and drainage provided through the gall-bladder. When the gall- 
ducts are infected, a rubber tube should be passed upward toward the 
hepatic ducts, and fixed in the line of incision with a catgut suture. After 
cholecystectomy a drainage-tube should be inserted down to the stump of 
the cystic duct. 

After an operation for perforating ulcer drainage will be indicated at the 
site of the lesion and elsewhere, if there has been extensive soiling of the 



660 GYNECOLOGY 

peritoneum. Drainage may not be required if the case is operated on 
within six hours. When, however, twelve hours have elapsed, it is safer to 
employ drainage. 

Pancreas. — Drainage should be employed in connection with every 
form of surgical operation on the pancreas. According to Moynihan, the 
only exceptions to this rule are cases in which no pancreatic fluid has 
escaped during the procedure, and the peritoneal incision used to expose the 
pancreas has been closed by suture. 

Kidney. — A paranephric abscess demands free drainage. After aseptic 
cases of nephrotomy, pyelotomy, or nephrolithotomy, when the kidney in- 
cision is clean cut and can be accurately approximated, no drainage is re- 
quired. If the incision is ragged or if there has been much traumatism, the 
paranephric tissues should be drained. Septic cases require drainage of the 
kidney wound itself and of the paranephric fat. 

After ureterotomy for stone or stricture, if the wound is ciean and well 
approximated, no drains are necessary, but otherwise a small rubber tube 
should be fixed at some distance from the line of sutures. 

Bladder. — Drainage of the female bladder is required after operation for 
vesical stone and fistula, and is readily accomplished by the introduction of 
a self-retaining (mushroom) catheter through the urethra. 

If the bladder is greatly inflamed and complete and constant drainage is 
desired, the organ should be opened at its base by an incision through the 
anterior vaginal wall. The vesicovaginal fistula thus made is kept open by 
the introduction of a mushroom catheter or by uniting the vesical to the 
vaginal mucosa. 

Post-operative Care in Drainage Cases. — Gauze packing introduced into 
the vagina or the uterus for the purpose of controlling hemorrhage should 
be removed w T ithin from twenty-four to thirty-six hours. Twenty-four hours 
after the introduction of gauze and rubber drains into the peritoneal cavity 
for the purpose of controlling hemorrhage, both the gauze and the rubber 
tubing may be removed, and the incision closed by tying the suture or 
sutures previously placed for that purpose. In cases of pelvic or abdominal 
infection drains must be allowed to remain much longer. The gauze inlays, 
if they fit the rubber tube loosely and do not project beyond it, should be 
removed at the end of twenty-four hours/ The rubber tubes are left in 
place until the fifth post-operative day. At that time the tubes are started 
(loosened), and every day after this an inch or more is cut off. The abdom- 
inal wound is dressed daily, particular care being used to keep the line of 
incision clean. It is advantageous to moisten the layers of gauze cover- 
ing the incision and the layer covering the drainage-tubes with a I : 2000 
solution of mercury bichloride. 

When gauze has been used in septic cases without a protecting rubber 
envelope, as in vaginal drainage into the pouch of Douglas, or when the 
gauze w T icks project considerably beyond the ends of the tubes, no attempt 
should be made to remove the gauze for from five to seven days. After 
this period a little at a time may be gently loosened each day, pulled out, and 
cut off. No force dare be used. Gauze drains loosen about the time they should 
be removed. Undue haste will break up protecting adhesions and may 



OPERATIVE TECHNIC 661 

cause an extension of the infection and peritonitis. Solutions of any sort 
must never be injected into an intra-abdominal drainage tract. 

Gall-bladder or bile-duct drainage is usually maintained for about ten 
days ; after this the tubes are gently tugged upon each day until they come 
away easily. In infected cases the drainage is allowed to remain for a 
longer time, or until the symptoms subside. Intraperitoneal drains intro- 
duced in connection with gall-bladder or gall-duct operations are treated in 
the same way as intraperitoneal drains in other localities. 

Kidney drainage, in septic cases, is continued until the symptoms sub- 
side and the wound is clean. When drains have been introduced for the 
purpose of effecting hsemostasis they may be removed at the end of twenty- 
four hours. (For a description of enteroclysis, which is frequently invalu- 
able when combined with drainage, see Chapter XXXVII, page 667.) 

BIBLIOGRAPHY 

Axspach, B. M. : " Experiences with Spinal Anesthesia in Pelvic Surgery." Amer. Jour. 

Obst., 1914, lxix, 3. 
Baldy, J. M. : "Surgical Injuries to the Ureters." Amer. Gyn. and Obst. Jour., 1894, v. 
Bevax, A. D. : " The Choice and Technique of the Anesthetic." Jour. Amer. Med. Assoc, 

1915, lxv, 1418; Ibid.: "On the Surgical Anatomy of the Bile-Ducts and a New 

Incision for Their Exposure." Annals of Surgery, 1899, xxx, 15. 
Bovee, J. W. : "Complete Sterilization of - the Skin by Iodine." Trans. Amer. Gyn. Soc, 

1914, xxxix, 379 ; Ibid. : " An Investigation of the Use of Iodine in Skin Sterilization 

for Surgical Purposes." Amer. Jour. Obst., 1911, lxiv, 91-106; Ibid.: "The Influence 

of the Trendelenburg Position on the Quantity of Urine Excreted During Anesthesia." 

Trans. Amer. Gyn. Soc, 1910, 443. 
Clark, J. G. : " A Critical Review of Seventeen Hundred Cases of Abdominal Section 

from the Standpoint of Intraperitoneal Drainage." Amer. Jour. Obst., 1897, xxxv ; 

Ibid. : " Intraperitoneal Drainage." Amer. Jour. Obst., 1897, xxxv, No. 4, 481. 
Coffey, R. C. : " Abdominal Adhesions." Trans. Sect. O. G. and A. S., A. M. A., 1913, 201. 
Crile, Lower : Anoci — Association. Saunders, Philadelphia, 1914. 
Farr : " Local Anesthesia in Abdominal Surgery," Trans. Sect. O. G. & A. S., A. M. A., 

1917, 164. 
Fixdley, P. : " Appendicitis Complicating Pregnancy, Labor, and the Puerperium." Amer. 

Jour. Obst., 1909, lx, 993. 
Fowler, G. R. : " The Toilet of the Peritoneum in Appendicitis." Trans. Amer. Surg. 

Assoc, 1903, xxi. 
Fowler, R. S. : The Treatment of Diffuse Septic Peritonitis Following xAppendicitis." 

New York Jour. Med., 1907, vii ; Ibid. : " Results in Diffuse Septic Peritonitis Treated 

by the Elevated Head and Trunk Pos-ition." Med. News, May 28, 1904. 
Franz, K. : " Die Schadigungen des Harnapparates nach abdominalen Uteruskarzinom- 

operationen." Zentralbl. f. Gyn., 1909, 601. 
Gellhorn, G. : " Spinal Anesthesia in Gynecology." Trans. Amer. Gyn. Soc, 1914, 

xxxix, 212. 
Gerster, O. G. : " On the Technical Considerations Influencing the Surgical Treatment of 

Appendicitis Occurring During Pregnancy." Phila. Month. Med. Jour., March, 1899, 

170. 
Grassich, A. : " Eine neue Sterilizierungs Methode der Haut bei Operationen, Vorlaufige 

Mitteilung." Zentralbl. f. Chir., 1908, xxxv, 1289. 
Graves, W. P. : " Division of the Ureter in Pelvic Operation." Boston Med. and Surg. 

Jour., 1917, clxxvi, 149. 
Hertzler, A. E. : " Local Anesthesia in Prevention of After-Pain and Shock." Jour. Amer. 

Med.' Assoc, 1914, lxiii, 2037; Ibid.: "Quinine and Urea Hydrochloride as a Local 

Anesthetic." ' "Jour. Amer. Med. Assoc, 1919, liii, 1393. 
Howland, J., and Richards, A. N. : "Experimental Study of the Metabolism and Path- 

ology'of Delaved Chloroform Poisoning." Jour. Exper. Med., 1909. 
Judd, E. S. : " Transplantation of the Ureter Following Traumatism and Resection of 

the Bladder for Cancer." Surg., Gyn. and Obst., 1917, xxiv, 635. 



662 GYNECOLOGY 

McArthur, L. L. : " A Modified Incision for Approaching the Gall-bladder." Surgery, 
Gynecology and Obstetrics, 191 5, xx, 83. 

McBurney : " The Incision Made in the Abdominal Wall for Appendicitis, with the 
Description of a New Method." Annals of Surgery, 1894, xx. 

Mayo, W. J. : " The Incision for Lumbar Exposure of the Kidney." Annals of Surgery, 
1912, lv, 63. 

Mayo-Robson, A. W. : " Modifications and Improvements in Operations on the Biliary Pas- 
sages." Brit. Med. Jour., January 24, 1903, 181. 

Murphy, J. B. : " Diffuse Suppurative Peritonitis." Trans. Amer. Assoc. Obst. and 
Gynecol., 1906, xix, 176. 

Noble, C. P. : " Overlapping the Aponeuroses in the Closure of Wounds of the Abdominal 
Wall." Annals of Surgery, March, 1906, 349. 

Norris, R. C. : " Operations During* Pregnancy." Chap, xxviii, Kelly-Noble Gynecology, 
vol. ii, Phila., Saunders, 1907. 

Olshausen : " tJber die Drainage." Zeit. f . Geb. u. Gynak., 1903, xlviii. 

Peaslee : " Infections into the Peritoneal Cavity after Ovariotomy." Amer. Jour. Obst., 
1871, iii, 300. 

Pfannenstiel : " liber die Vortheile des suprasymphysaren Fascienquerschnitt fur die 
gynakologischen Koliotomien, zugleich ein Beitrag zu der Indikationsstellung der 
Operationswege." Samml. klin. Vortr., Leipzig, 1900, No. 268. 

Sampson, J. A. : " Ligating and Clamping the Ureter as Complications of Surgical Opera- 
tions." Amer. Med., 1902, lv. 

Scheib, A. : " Klinische und anatomische Beitrage zur operativen Behandlung des Uterus 
Carcinoms." Archiv f. Gyn., 1909, lxxxvii, 1-233. 

Stoeckel : " liber die Behandlung des Verletzten und Unverletzten Ureters bei Gynakolo- 
gischen Operationen." Zeit. f. Gyn., Urologie, 1911, Bd. iii, S. 51. 

Sweet, J. E., Chaney, R. H., Wilson, H. L. : " Prevention of Post-operative Adhesions 
in Peritoneal Cavity." Annals of Surgery, 191 5, lxi, 300. 

Teter, C. K. : " Nitrous Oxid-Oxygen in General Surgery and Obstetrics." Lancet Clinic, 
Cincinnati, O., 1914, cxii, 627. 

Trendelenburg, F. : " liber Blasenscheiden — Fistel Operationen, und liber Beckenhoch- 
lagerung bei Operationen in der Bauchhohle." Volkmann's Sammlung klinischer 
Vortrage, 1890, No. 355 (Chirurgie No. 109). 

Whipple, G. H., Sperry, J. A. : " Chloroform Poisoning, Liver Necrosis and Repair." 
Bulletin Johns Hopkins Hospital, September, 1909. 



CHAPTER XXXVII 
POST-OPERATIVE TREATMENT 

Nausea and Vomiting. — After ether, and to a less extent after chloroform 
anaesthesia, there may be considerable nausea and vomiting; this usually 
subsides in from six to eighteen hours. It may be difficult to relieve. The 
patient should be carefully observed, so that none of the vomitus is aspi- 
rated into the trachea. For this reason, during the retching and straining, 
the head of the patient should be turned to one side, the angles of the jaws 
pressed forward, and the mouth held open, in order to permit ready escape 
of the regurgitated material. Most patients complain of thirst, but water, 
except in small amount, is promptly ejected from the stomach. Where 
the vomiting is not attended by danger to the patient, she should be encour- 
aged to drink freely of warm water containing a little (2 per cent.) bicar- 
bonate of soda or common salt. This is either quickly rejected by the 
stomach, or passes through the pylorus into the bowel. In either case relief 
will be obtained, which may indeed be but temporary, so that the expedient 
may have to be repeated when the retching and nausea return. 

If it is especially desirable to keep the patient quiet and to avoid violent 
contractions of the diaphragm and the abdominal wall, then one gives no 
water by mouth but relieves the thirst, as far as possible, by applying cold 
compresses to the lips and giving small bits of cracked ice. In the mean- 
time enteroclysis, with 2 per cent, soda bicarbonate solution, will gradually 
relieve the intense thirst. 

Thirst. — Post-operative thirst may be in a measure anticipated by intro- 
ducing a quart or two of 2 per cent, soda bicarbonate solution into 
the sigmoid and colon before the patient leaves the operating table. The 
enteroclysis may be repeated at intervals of from three to six hours, from 
eight ounces to a pint of solution being used at a time. The solution is run 
slowly into the rectum through a soft-rubber catheter ; this can be accom- 
plished easily in thirty minutes, when the catheter should be removed. For 
most patients interrupted is more comfortable than continuous enteroclysis. 
After the patient is able to take fluids by the mouth, the quantity and fre- 
quency of the saline infusions may be reduced. 

Pain. — When morphine and atropin are given routinely either be- 
fore or immediately after operation, the patient does not complain much 
of pain within the first few hours. As a rule, she sleeps or is drowsy. If, 
after the patient is well out of the anaesthetic and the effect of the hypo- 
dermic injection has worn off, there is marked pain, or if she is restless or 
apprehensive, heroin in 1/12 grain doses by hypodermic injection may be 
given, and repeated as required, but at most not oftener than every three 
hours. By this means the patient is kept quite easy during the first twenty- 
four hours, and in the majority of cases is spared the great distress and 
discomfort which would otherwise follow. 

663 



664 GYNECOLOGY 

Diet. — Immediately after operation the patient has no desire for 
solid or semi-solid food ; but there is a great craving for liquids, and after 
the first six or eight hours, or as soon as the stomach displays a tendency 
to be retentive, the patient should be allowed small sips of plain hot water, 
albumin water, milk and lime water (equal parts), or buttermilk or weak 
tea (i to 4 drams every half hour). As the stomach becomes more reten- 
tive, the amount taken may be increased to I to 2 ounces every hour. Dur- 
ing the first three days of the convalescence nothing but fluids should be 
given, but after the third day, if the bowels have been moved satisfactorily 
and the patient manifests no disquieting abdominal or general symptoms, 
soft, semi-solid food may be given, and in the course of two or three days 
more this may be increased to the regular house diet. 

Departures from this course must be made under some circumstances. 
If the operation has involved the upper part of the alimentary canal, the 
amount of liquid taken by the mouth must be restricted, the thirst and crav- 
ing for liquids being assuaged by the use of soda solution introduced into 
the bowel. When the operation has involved the lower part of the intestinal 
tract, there is little danger from the use of liquids by the mouth, even in 
considerable quantities, but if the colon, or especially the sigmoid flexure or 
the rectum, has been affected, enteroclysis must be avoided. After com- 
plete tear operations, or when it is desirable to avoid abdominal distention 
or the use of enemas or purgatives for a considerable time, the diet should 
be restricted entirely to albumin water, which is readily absorbed and quite 
fully digested, so that little residue is left in the bowel. 

Bowels. — In the average patient (drainage cases and complete tear 
operations excepted) it is Avell to leave the bowels undisturbed until seventy- 
two hours have elapsed from the time of operation, when a simple enema, con- 
sisting of soapy water (1 to 2 pints) may be given. This usually has the 
desired effect, the bowels moving freely and considerable gas being expelled. 

If the simple enema is not effectual, a compound enema (Epsom salts, 
2 ounces; glycerine, 2 fluidounces ; sweet oil 4 fluidounces ; water, sufficient to 
make 1 pint) should be introduced through a tube, passed into the sig- 
moid flexure; or an enema of glycerine (4 ounces) or one of alum (1 
to 4 drams to 1 pint of water) may be tried. Plenty of time should be 
given for one enema to act before another is ordered. The patient may 
be much distressed by too great haste. For the first five days the bowels 
should be moved daily with an enema. At the end of that time when the 
temperature is normal and there are no indications of peritonitis or obstruc- 
tion of the bowel it is well to give the patient some simple laxative every 
night (paraffine oil, 4 drams with cascara, 2 grains or phenolphthalein, 2 
grains), supplemented by an enema in the morning, if necessary. 

In drainage cases it is good practice to make no attempt to move 
the bowels for five days, the only indications for the use of the rectal tube or 
a simple enema being undue distention of the abdomen and inability of the 
patient to pass flatus. If the abdomen remains fairly flat and the patient 
does not complain of gas pains, it is well not to disturb her until the end 
of the fifth day, when an enema may be given. This should be repeated 
daily until the tenth day, when mild laxatives may be started (see page 665). 






POST-OPERATIVE TREATMENT 665 

After complete tear operations, the bowels should be kept locked for a 
week, no enemas being permitted during that time, and the patient being 
allowed nothing but liquid food in minimum amount. About the fifth day, 
paraffin oil should be given in dose of 4 fluid drams three times a day, and on 
the seventh day, an ounce or two of castor-oil. Thereafter, the mineral oil 
should be continued daily combined with cascara or phenolphthalein. 

If, during the first post-operative week the patient becomes very uncom- 
fortable by reason of an accumulation of gas or faeces in the lower bowel, 
a small enema may be given through a soft-rubber catheter, well lubri- 
cated, and passed w T ith great care through the sphincter. During the 
insertion of the catheter, it should be pressed against the posterior com- 
missure so as to avoid the line of suture. The nurse must be carefully 
instructed upon this point. 

The use of cathartics immediately after operation is contraindicated. If 
the patient has been properly prepared, there is nothing in the intestinal 
tract that must be expelled at once, so that there is no need for active 
catharsis. On the contrary, it is generally better to limit peristalsis for 
the first forty-eight hours. This is particularly true if there is imminent 
danger of peritonitis, for then peristaltic action will tend to spread infec- 
tion. Cathartics are capable of much mischief if there is partial obstruc- 
tion or a kink in the bowel or if the integrity of the alimentary tract has 
been threatened by the operation. In other words, in the early post-opera- 
tive days cathartics are troublesome and produce discomfort ; they are 
unnecessary, and they are often harmful. Their use should be avoided 
until the danger of peritoneal and gastro-intestinal complications is over. 
After the bowels have been well moved by enemas, the temperature and the 
peristalsis have returned to normal, and the patient takes food without 
discomfort, a mild laxative may be employed daily if necessary. 

Bladder. — The urinary excretion is always diminished after opera- 
tion because of the restriction of liquids and the thorough evacuation 
of the intestinal tract previous to anesthetization. If salt solution has been 
given subcutaneously or soda solution has been injected into the 
bowel, at the close of the operation the urinary excretion will be increased, 
but it rarely exceeds 24 fluidounces during the first post-operative day ; 
after this, in normal cases, it increases with the amount of liquids ingested. 
As so many gynecologic operations involve the bladder or its neighboring 
structures, it is generally advisable to avoid any great distention of the 
bladder within the first few days of the operation. It is a good rule, there- 
fore, to have the patient void urine or to catheterize her within eight hours, 
and to repeat the process at eight-hour intervals. After suspension of the 
uterus, operations for shortening the round ligaments, extensive operations 
for cystocele, etc., the bladder should be emptied every six hours during the 
first two days. If the amount excreted during the first twenty-four hours 
falls below 16 fluidounces, the urine should be examined and a careful 
investigation made for possible sources of suppression or retention. Most 
patients are able to empty their bladder voluntarily after the second or 
third day. There are some exceptions, however, in which repeated catheter- 
ization is necessary for a week or more. Taussig showed that retention 



666 



GYNECOLOGY 



was most common after interposition operations for prolapse and radical 
operations for cancer of the cervix. He says that the important factors in 
urinary retention are interference with the blood-supply of the bladder, 
direct or indirect pressure or irritation about the urethral sphincter, excision 
of the nerve supply of the bladder, and interference with the control of 
the central nervous system, through anaesthetics, narcotics, or mental pro- 
cesses. As the continued use of the cathe- 
ter predisposes to cystitis, the patient 
should be encouraged to void urine volun- 
tarily ; during the effort an elevated pos- 





FiG. 494. — Enteroclysis ap- 
paratus with visible drip. 



Fig. 495. — Visible drip glass con- 
necting tube. 



ture may be assumed and will often prove helpful ; the sound of running 
water acts sometimes as a suggestion. Late in the convalescence the 
patient may be allowed to step out of bed and use a commode. Injec- 
tions of the extract of the pituitary gland (pituitrin, 1 ampoule) will often 
stimulate the smooth muscle-fiber of the bladder sufficiently to bring about 
evacuation of the bladder. The sphincter muscle of the bladder is some- 



POST-OPERATIVE TREATMENT 



667 



times relaxed by a low enema of warm saline solution, and this may have 
the desired result. A plan that is sometimes successful consists in inject- 
ing into the bladder, when the patient expresses a desire to void urine, one 
ounce of sterile glycerine. If no result follows the first effort, it may be 
repeated several times, since it does no harm. If there is no result within 
thirty minutes of the injection, the patient should be catheterized. The 
most scrupulous care must always be taken in performing catheterization 
in post-operative cases. 




Fig. 496. — Bed with head elevated. 



Enteroclysis is an important part of the after-treatment in many cases. 
Two per cent, sodium bicarbonate solution, normal salt solution, or tap 
water may be used. Ordinarily, sodium bicarbonate (2 per cent.) solution 
is preferable. The solution may be thrown into the bowel at the close of the 
operation in one large injection (1 to 2 liters) while the patient is still under 
the influence of the anaesthetic, or it may be given later by continuous or 
interrupted enteroclysis. Enteroclysis is a valuable method of supplying 
fluids to the body when they cannot be ingested or when it is inadvisable 
to give them by the mouth. 



668 



GYNECOLOGY 



By the term continuous enteroclysis is understood the continuous intro- 
duction of solution in quantities proportionate to the rate of absorption. By 
interrupted enteroclysis is meant the introduction into the rectum, at inter- 
vals, of fluid in such quantity as can be retained comfortably and readily 
absorbed within an estimated period of time. For either method a small 
rubber catheter is passed as high into the rectum as it will go without 
causing discomfort, and attached to a reservoir containing the solution. In 
continuous enteroclysis a visible drip may be used, so that the rate of flow 
can easily be regulated ; this is done either by compression of the hose or by 
the degree of elevation of the reservoir. Thirty drops a minute amount to 
nearly six pints in twenty-four hours. By the interrupted method one pint 
of solution may be run into the bowel immediately after the operation ; 
from eight to twelve ounces may be slowly introduced every three hours, 
about a half hour being consumed with each injection. 




Fig. 497- — Fowler bed. 



In desperate cases continuous enteroclysis will be the most satisfactory 
method, whereas for the ordinary post-operative treatment, the interrupted 
form will be associated with less discomfort to the patient. 

As convalescence progresses, the frequency of the rectal infusion may 
be lessened as the intake by the mouth is increased. 

Posture. — During the first post-operative hours the patient is al- 
lowed to remain flat on her back. When the effect of the anaesthetic 
begins to wear off the trunk should be elevated (Fig. 497). This may be 
accomplished in several ways : blocks may be placed under the head of 
the bed, a portable elevating frame may be placed on the bed, or the 
shoulders and head may be raised with pillows. In any of these plans 
the tendency of the patient to slip down may be combatted by placing a 
sand-bag and pillow beneath the buttocks ; these are held in place with a 
length of stout muslin bandage fastened to the frame of the bed. Such 
elevation of the trunk and support of the buttocks are much facilitated when 
the bed is fitted with a Gatch frame, as shown in Fig. 497. 



POST-OPERATIVE TREATMENT 669 

Elevation of the trunk or the Fowler position is more conducive to com- 
fort than the horizontal position. It promotes the drainage of peritoneal 
fluids into the pelvis, localizes peritoneal infection to that region, and hin- 
ders the development of a general peritonitis. In cases of threatened cardiac 
1 dilatation it relieves the congested right heart. It also prevents hypo- 
static congestion of the lungs. 

Elevation of the pelvis, or the Trendelenburg position, which is the 
opposite of the Fowler position, is used as a post-operative measure only in 
shock and cardiac failure from hemorrhage. In this position the weight of 
the venous column of blood upon the right heart promotes contraction of 
that organ and stimulates the circulatory function ; it is never used for any 
length of time. As soon as reaction is established the Fowler position 
is resumed. 

In cardiac failure from right-sided hypertension or dilatation, this posi- 
tion is contraindicated. Under such circumstances the Fowler position 
should be instituted at once (see Post-operative Cardiac Dilatation, p. 692). 

Out of Bed. — Following the average laparotomy or perineal operation, 
the patient is permitted to get out of bed on the tenth day- In the case of 
extensive plastic and suspensory operations this may be delayed until the 
fourteenth day. 

In all cases in which convalescence has progressed normally the patient 
may walk about at the end of two weeks and from that time onward gradu- 
ally resume her usual activities. 

Six weeks should be allowed for complete convalescence, and strenuous 
exercise and hard work should be avoided for at least that period. 

Dressing the Incision. — Unless there are symptoms of infection or 
hemorrhage, the celiotomy incision should not be disturbed for a week or 
ten days. At that time the wound is inspected, non-absorbable sutures are 
removed, the skin is cleansed with alcohol, and a fresh dressing is applied. 

The wound should be protected with a gauze dressing until healing is 
complete and the scar is smooth and dry. 



CHAPTER XXXVIII 
POST-OPERATIVE COMPLICATIONS 

SHOCK 

Cause. — Shock is the depressing influence on the cerebrospinal system 
that results from hemorrhage, prolonged anaesthesia, severe pain, extensive 
trauma, and exposure and handling of the abdominal viscera. The effect is 
believed to be brought about by afferent nerve impulses or by impoverish- 
ment of the circulating blood. The most frequent cause is loss of blood, 
but all the other factors play a part, and occasionally they play the 
leading role. 

The pathologic condition is not definitely known ; but an anaemia of the 
brain, a loss of control of the vasomotor centers, a diminution in the tone of 
the blood-vessels, an accumulation of the blood in the larger venous trunks 
of the splanchnic plexus, and a weakening in the force of the circulation are 
said to be present. Shock is observed during, immediately after, or within 
a few hours of operation. 

Symptoms. — The symptoms of shock are pallor and cold perspiration ; 
the pulse is rapid, weak, and easily compressed, and in severe cases it is 
almost imperceptible ; the respirations are rapid and shallow ; the face is ex- 
pressionless ; the jaw drops, the eyes are dull and staring, the pupils react 
very slowly, and the temperature is one or two degrees below the normal. 
Shock must be differentiated from secondary hemorrhage and acute post- 
operative dilatation of the heart (see Hemorrhage, p. 6j2, and Acute Post- 
operative Dilatation of the Heart, p. 690). 

Treatment. — Treatment must be promptly and energetically applied. 
The foot of the bed should be elevated, the head and chest of the patient 
should be low, in order to favor the return of venous blood to the heart. 

If operative hemorrhage has been the cause, the lower extremities from 
the soles to the groins may be tightly bandaged. 

The patient should be surrounded by hot-water bottles and blankets ; in 
extreme cases massage and vigorous rubbing may do some good. Stimu- 
lants, such as extract of the pituitary gland (pituitrin, 1 ampoule), strychnine 
(1/30 to 1/15 grain), camphor (1 to 2 grains), in sterile sweet oil, should be 
administered hypodermically. A hot enema of black coffee is often of con- 
siderable benefit, and whiskey (1 ounce to 2 pints of saline solution) may be 
administered in the same manner. 

Hypodermoclysis, or the intravenous injection of normal saline solu- 
tion, is of the greatest value. The addition of suprarenal extract (adrenalin 
chloride, 5 to 10 minims to each pint of the salt solution) will help restore 
vasomotor tone. If the patient is restless or complains of pain while these 
procedures are being carried out. hypodermic injections of morphine and 
atropin may be used with great advantage. Improvement in the patient's 
condition may be rapid or slow, or the symptoms may become increasingly 
670 



POST-OPERATIVE COMPLICATIONS 671 

worse and death ensue. If improvement sets in, the treatment just out- 
lined may be continued, guarding the patient against overstimulation. 

Shock may be avoided by carefully preparing the patient for operation, 
curtailing the anaesthesia, limiting the loss of blood, and avoiding as much 
as possible undue exposure and handling of important viscera (see Chapter 
XXXVI). 

HEMORRHAGE 

Varieties. — Hemorrhage following operation may occur in a number of 
forms. Thus it may be: (i) A slow, continuous ooze from the capillaries 
of a raw surface ; (2) a steady flow from a vein ; or (3) an active spurt from 
an artery. Post-operative hemorrhage may be a continuation of the hemor- 
rhage that took place at the time of the operation, and that was not entirely 
controlled, or it may be due to the slipping of a ligature some time later, or it may 
be the result of the infection and disintegration of an occluding thrombus. 

Capillary Oozing. — A certain amount of capillary bleeding is bound to 
occur when Extensive adhesions have been separated, and although the hemor- 
rhage usually ceases spontaneously, at times it persists in sufficient amount to re- 
quire treatment. Just to what extent this bleeding should be checked must be left 
to the discretion of the operator. The more actively bleeding areas should in- 
variably be controlled with mattress sutures ; for the less active ones, and for 
those in such a position that the application of sutures is impracticable or dan- 
gerous, compression for a few minutes with a sponge wrung out of very hot 
water will often suffice. In doubtful cases a safe plan is to use a gauze pack for 
twenty-four hours ; the objections to this plan are, however, as numerous as to 
drains in general. Nevertheless, if the oozing is free, a pack may be necessary. 
In the less marked cases, if it is certain that the main vessels have been tied 
securely, the oozing may be disregarded, the operator being justified in believing 
that a clot will form and the hemorrhage cease within a reasonable time. 
Occasionally, even under such circumstances it will continue, and a consider- 
able amount of blood accumulate in Douglas' pouch ; here it may be absorbed 
or encapsulated (hematocele). These cases do not, however, present the 
alarming symptoms of a secondary hemorrhage ; very often, unless infec- 
tion occurs, a slight increase in the pulse-rate being the only early symptom, 
and those attending the formation of a hsematocele the only late ones. 

Venous and Arterial Hemorrhage. — Venous and arterial hemorrhage is 
usually the result of the slipping, breaking, or premature absorption of a 
ligature. The most frequent cause of hemorrhage of this form is the tying 
of vessels or pedicles en masse and cutting too close to the ligature. If the 
pedicle is on tension, the straining incident to post-operative vomiting may 
release it from the grasp of the ligature. To avoid such a catastrophe, it is 
advisable to tie all large vessels individually in their course, or when tying 
en masse to transfix the stump, tie both ways, and leave the stump at least a 
centimeter in length and free of any tension. If catgut is selected as the 
ligature material, a gut that is not absorbed in less than ten days should be 
used, and all large vessels, such as the uterine and the ovarian, should be 
doubly secured. If silk is used, one ligature usually is sufficient, but in case 
of doubt, an additional one of catgut may be tied. 



672 GYNECOLOGY 

Hemorrhage from cervical or vaginal wounds occasionally occurs as late 
as ten days or two weeks following operation, after absorption of the catgut, 
which either releases an arterial or a venous trunk or permits the sepa- 
ration of two surfaces, as, e.g., the lips of the cervix, whose vessels have been 
controlled by close approximation. Even when this occurs, if infection has 
not taken place, hemorrhage is unlikely to ensue. A vessel that has been 
secured successfully by an aseptic ligature is soon occluded by an obliter- 
ating angeitis, or by an aseptic blood-clot that undergoes organization 
within a short time, so that absorption of the ligature after ten days under 
normal conditions would make no difference. If, however, there has been 
an infection, or if the inner coats of the vessel beyond the point of ligation 
have been injured by compression, the obliteration is delayed or an infected 
clot is formed that is prone to undergo disintegration and to be discharged 
from the vessel, thus promoting hemorrhage. 

Hemorrhage after plastic operations is usually limited and readily con- 
trolled. Occasionally, because of the extensive loss of blood, the hemor- 
rhage may give rise to alarming symptoms, and owing to the narrowing 
of the vaginal introitus, the bleeding area may be hard to expose and the 
hemorrhage difficult to stop. If simple packing does not suffice, the patient 
should be placed in the lithotomy position, an anaesthetic administered if 
need be, the parts freely and carefully exposed and illuminated, and addi- 
tional sutures introduced to catch the bleeding points, 

Hemorrhage of the grave and serious type occurs from operative areas 
within the pelvis where the bleeding cannot be seen, and the general symp- 
toms are the only indication. Such hemorrhage may vary from an 
exceedingly rapid type in which the patient dies within thirty minutes, to 
those in w T hich the loss of blood is less rapid and the patient succumbs in 
the course of hours, or in the event of alternate clotting, and renewed bleed- 
ing in the course of days. 

Symptoms. — The most striking symptoms of this complication are a sud- 
den increase in the pulse-rate, with diminished volume, and a subnormal 
temperature. The patient may complain of severe pain at the site of the 
bleeding vessel. The face is pale and anxious, the respirations are hurried, 
and in severe cases the auxiliary muscles are called into play. The mind is 
clear, but the speech is hurried and broken, and the patient is restless. If 
the bleeding continues the pulse becomes imperceptible at the wrist; the 
skin is cold and clammy, the dyspnoea is marked, consciousness is lost, the 
pupils dilate, and death finally ensues. 

Diagnosis.— The symptoms are those of shock, already described (see 
page 671). Shock from hemorrhage and shock from other causes have few 
points of differentiation. Many cases of serious shock are in reality 
instances of hemorrhage. In true shock there is an accumulation of most 
of the blood in the splanchnic vessels. Whether or not hemorrhage is 
actually taking place may be judged best by the nature of the operation 
that has been performed, the care exercised, and the difficulty experienced 
in securing haemostasis. Other factors, such as the general condition of the 



POST-OPERATIVE COMPLICATIONS 



673 



patient previous to operation, the duration of the anaesthesia, and the 
amount of traumatism and exposure of the viscera, must also be taken into 
account, and will usually assist the examiner in reaching a correct diagnosis. 
Certain rapid cases of peritonitis may show symptoms closely resembling 
those of serious internal hemorrhage, but in the former there is usually a 
slight elevation of temperature and other signs, such as diminished peri- 
stalsis, which serve to distinguish between the two conditions. 

The appearance of the subcutaneous blood-vessels may help to dis- 
tinguish between a rapid, feeble pulse due to internal hemorrhage and 
one due to other causes. If the blood-vessels on the back of the hand, upon 
the forearm, at the bend of the elbow, and on the temples are well filled, it is 
unlikely that serious loss of blood has taken place. 

An estimation of the haemoglobin or a red and white blood count may 
also form a basis for differentiation. With a severe internal hemorrhage, all 
constituents except the leucocytes are greatly diminished ; in the presence 
of sepsis, there is no marked change in 
the haemoglobin and the red cells, but the 
white cells are increased in number. 

Treatment. — The treatment of in- 
ternal hemorrhage is that previously 
advised for shock, plus prompt liga- 
tion of the bleeding vessel or vessels. 
Cases of internal hemorrhage of mod- 
erate degree undoubtedly occur in 
which absolute rest and quiet, with 
gentle stimulation, will tide the pa- 
tient over the critical period and the 
bleeding will cease ; the attainment of 
so fortunate a result is never certain, and 
if the symptoms are marked and the 
diagnosis is reasonably positive, prompt action must be taken to secure the 
bleeding vessels. The patient should, with as little disturbance as possible, 
be placed upon an operating table, an anaesthetic administered, the dress- 
ings removed, the wound opened, and the pelvis well exposed, so as to learn, 
with the\east possible delay, the source of the hemorrhage. If the continu- 
ous bleeding makes it manifestly impossible to expose the operative area 
quickly, clamps may at once be applied by the sense of touch alone, upon the 
uterine, ovarian, and round ligament vessels on each side. If the patient is 
in a desperate condition and the bleeding point is situated deep in the pelvis, 
as after a total hysterectomy, the pelvis may be packed with gauze, a firm 
pack placed in the vagina, and suprapubic and perineal counter-pressure 
may be maintained for a time until clots have had time to form. This may 
be of no avail in the case of a spurting artery, but will often be useful in 
venous hemorrhage or in oozing. The intravenous injection of horse serum 
may be tried. 

Stimulation in a case of internal hemorrhage should be postponed until 
the bleeding vessel is caught (see also Extrauterine Pregnancy, page 373). 
43 




Fig. 498. — Portable heat cabinet, useful in treat- 
ment of pelvic inflammatory disease. 



674 GYNECOLOGY 

EXCESSIVE NAUSEA AND VOMITING 

Etiology. — Nausea and vomiting are common after anaesthesia, but usually 
subside gradually within the first twenty-four hours. Occasionally they 
persist in an aggravated form for a much longer period, giving rise to 
considerable apprehension that all is not going well with the patient 
and that peritonitis or obstruction is impending. Although these symp- 
toms may actually be due to an incipient peritonitis that undergoes 
resolution, or to a partial slight obstruction that is subsequently relieved, 
they are apparently frequently due to a hypersusceptibility on the part of 
the patient toward emesis, and a marked aversion to ether or to the anaes- 
thetic that has been used. Nausea and vomiting have been ascribed to an 
increased action of the ether on the vomiting center in the medulla, or to an 
excess of mucus, which becomes impregnated with ether and is swallowed, 
giving rise to irritation of the gastric mucosa. 

Treatment. — As exaggerated nausea and vomiting may be an indication of 
serious post-operative disorders, such as acidosis or acute gastric dilatation, peri- 
tonitis, or obstruction, the following measures may be employed until the 
diagnosis is clear : Ice-bags should be placed upon the lower abdomen ; the 
patient should be kept in the Fowler position. If the abdomen is dis- 
tended, a simple enema may be given. When the distention involves the 
upper abdomen especially, the stomach-tube should be passed and lavage 
practised. The urine should be examined for acetone and diacetic acid, and 
if either is present, sodium bicarbonate, 10 grains, should be given by 
mouth every three hours, or continuous enteroclysis with a 2 per cent, solu- 
tion should be used. In desperate cases the intravenous injection of one pint of 
a 1 per cent, solution of sodium bicarbonate should be employed. 

Regardless of all treatment, and without the development of any serious 
disturbance, the vomiting may continue. Under such circumstances the 
plan previously outlined should be followed until the symptoms subside. 
Nothing should be given by the mouth except sufficient water to control 
the thirst. 

TYMPANITES 

Etiology. — Extreme distention may be an indication of peritonitis, obstruc- 
tion, or acute gastric dilatation. It may be; the result of a transient 
paralysis of the bowel following operations in which the intestine has been 
considerably handled, or it may result from chronic gastritis or enteritis, 
plus incomplete evacuation of the intestinal tract before operation, and 
subsequent fermentation. There is usually recurring colicky abdominal 
pain (gas-pains). The condition may be accompanied by other disturbing 
symptoms, such as increased pulse-rate, elevation of temperature, and nausea 
and vomiting, or it may exist alone. 

Treatment. — If peristalsis is normal, the distention may be regarded with 
equanimity, as it will usually be relieved promptly by a high compound enema 
and the application of heat to the abdomen. If violent peristalsis is present, so as 
to be audible to those about the patient, obstruction is quite possible, and 
the case assumes a more serious aspect, especially if other indications of 
obstruction, such as nausea and vomiting, are present. 



! 



POST-OPERATIVE COMPLICATIONS 675 

The complete absence of peristalsis is almost invariably an ominous sign, 
and often indicates peritonitis, but here again the pulse and temperature 
must be taken into account. Faint peristaltic sounds may point to a tran- 
sient post-operative paresis of the bowel. 

The treatment of simple tympanites consists in the application of heat 
to the abdomen, and the use of rectal suppositories of asafetida (5 grains) 
every three hours. If flatus is not soon expelled, a simple enema of soapy 
water (1 pint) may be given; later, if necessary, an enema composed of 
epsom salts (2 ounces), glycerine (2 ounces), sweet oil (4 ounces), and 
water (2 pints) should be injected through a soft rectal tube passed high up 
into the bowel. Occasionally if the rectal tube is left in situ this will result 
in the passage of gas. An enema of pure glycerine or of alum (1 dram to 
1 pint) or the milk of asafetida (1 ounce to 1 pint) may be effectual. 

Various drugs have been recommended ; of these the best is pituitary 
extract (pituitrin, 1 c.c.) given hypodermically. Eserine (gr. 1/60) and 
atropin (gr. 1/150) every three hours are recommended by some clinicians. 
The use of cathartics is unwise. The patient should receive practically 
nothing by the mouth if the thirst can be controlled with saline enemas, 
about 8 ounces every three or four hours. This has also frequently a benefi- 
cent effect on peristalsis and on the expulsion of gas. 

PERITONITIS 

Etiology and Pathology. — Peritonitis following operation is caused by 
the deposit of infectious organisms in the peritoneal cavity during the surgi- 
cal procedure. These organisms may be carried on the hands of the oper- 
ator or of his assistants, or be transmitted on the sutures, dressings, water, 
and other materials used in the operation, or they may come from foci of 
infection in the patient which have been invaded and liberated during the 
course of the operative procedure. 

Peritonitis may be limited in its extent and localized to a particular" 
region, or be unlimited and diffuse. 

Following almost every operation there is more or less inflammatory 
reaction in the operative area, due chiefly to the mechanical insults to which 
the parts have been subjected. This quickly subsides, and does not give rise 
to constant or serious symptoms. When infection is added to the trauma, a 
bacterial invasion of the peritoneal surface takes place, with the formation of 
inflammatory products and the production of certain clinical manifestations. 

The inflammation of the peritoneum becomes limited or unlimited, ac- 
cording to the virulence of the infecting organism, the resistance of the 
patient, the treatment employed, and the mechanical factors predisposing to 
one or the other. Thus, for example, a streptococcus infection is more apt 
to spread throughout the peritoneal cavity than is one that is caused by the 
gonococcus or the colon bacillus. Pelvic infections are more likely to re- 
main localized than are those occurring above the brim of the pelvis, since 
the location and the surroundings of the pelvis favor localization to that 
area; furthermore, the Fowler position, the application of cold, the avoid- 
ance of cathartics, and the use of opiates will arrest peristalsis and be con- 



676 GYNECOLOGY 

ducive to localization, whereas the horizontal position, cathartics, and the 
omission of the local application and the opiate will favor peristaltic move- 
ment of the intestines, extension of the infection, and generalization of the 
inflammatory process. 

The gross appearances of the peritoneal cavity at operation or post- 
mortem have led to various classifications of peritonitis ; these are both un- 
necessary and arbitrary, so far as the clinician is concerned. The morbid 
changes that take place depend upon the nature and virulence of the infect- 
ing organism, the resistance of the patient, the duration of the disease, and 
the peculiar circumstances of the case. 

Certain infections are of so virulent a type that the patient succumbs 
before marked changes take place in the peritoneum ; others are so slow that 
any of the various stages of inflammation, effusion, lymph-formation and 
exudate, and finally pus formation may be observed. In some of the violent 
and fulminating types following operation, the peritoneal cavity contains 
only bloody serum with a few flakes of lymph, although the. serous mem- 
brane itself has lost its clear, translucent appearance, is injected and red, 
and the intestines are distended with gas. When a later stage is reached, 
the intestinal coils are covered with flakes and patches of lymph that adhere 
closely, neighboring coils are more or less bound together with the plastic 
lymph, the fluid is a cloudy gray, less bloody than at first, and smaller in 
amount. To this succeeds the purulent stage, when the lymph is replaced 
by pus, the peritoneal fluid is purulent, the intestines are covered with a 
yellowish, adherent, membranous deposit, and many adjacent loops are 
closely matted and bound together, surrounding pools of purulent material. 
All these manifestations may be more pronounced in the area where the 
infection has begun, gradually diminishing the deeper one looks into the 
peritoneal cavity. Indeed, a peritonitis involving every part of the peri- 
toneal cavity is somewhat rare, except in the very latest stages. In the 
rapidly fatal forms the patient is killed by toxins before there is any attempt 
at localization, such as a matting together of the intestinal loops by lymph 
always indicates. 

Any peritonitis, even though it threatens to become general, may, with 
proper treatment, if taken in time, become localized. If the toxic products 
are but moderately poisonous ; if the resistance of the patient is good ; if the 
intestinal coats have not been damaged beyond repair, and the integrity of 
the intestinal tube is not destroyed by adhesions and inflammatory deposits, 
the general condition of the patient may gradually improve as the pus be- 
comes localized and the disease confines itself to a certain area. 

Symptoms. — The symptoms of peritonitis are many and varied. No 
one of them alone is a certain indication of the disease, and it is only by a 
combination of several that a conclusion can be reached. Increase of the 
pulse-rate, elevation of temperature, intestinal paresis, tympanites, nausea, 
vomiting, and a peculiar fades make up the symptom-complex. In the 
early stages rapidity of the pulse and a limitation or an abrogation of in- 
testinal peristalsis are the most significant symptoms. The temperature is 
usually elevated to a point higher than is common in the normal post- 
operative convalescence (ioo°), and at times it is elevated to 103 or 104 F. 



POST-OPERATIVE COMPLICATIONS 677 

In some cases, however, the temperature is only moderately elevated until 
the patient is in extremis. The abdomen is distended and tense, the walls 
are rigid and spastic, and the patient complains of pain when the ear of the 
examiner or a stethoscope is applied to detect the peristaltic sounds. As a 
rule, these are greatly diminished or absent, and nothing is heard but the 
rapid beating of the abdominal aorta. 

Enemas given for the relief of tympanites are usually ineffective, or but 
slightly successful ; in any case, they fail to relieve the distention. The 
patient complains of nausea, and rejects anything given by the mouth from 
time to time. At first the stomach may show some tolerance, but this stage 
does not last long. Even if fluids are withheld, in the later stages there is 
vomiting of bile, and at length of fecal matter, which has been driven into 
the stomach from the distended and paretic small intestine. 

The patient is toxic, feverish, restless, and presents the flushed cheeks 
and bright eyes that accompany an elevation of temperature. At first the 
mind may be clear, but it soon becomes confused; delirium, hiccough, and a 
semi-stuporous condition often supervene. The pulse becomes progressively 
faster (150 to 160) and weaker, later intermittent, and finally, imperceptible. 
The respiratory rate is proportionately increased. 

The course of the case varies with the virulence of the infection, the 
extent of the lesion, and its complicating or associated conditions. A peri- 
tonitis engrafted upon an already shocked or acutely anaemic person is much 
more likely to spread quickly and end fatally than is one in which the 
opposite conditions prevail. So, too, if a partial obstruction of the intestinal 
tract coexists, the case will run a decidedly less favorable course than it 
would otherwise. 

Perforation of the gut or leakage from a wounded ureter or bladder 
exerts a decidedly deleterious influence and makes resolution improbable 
and almost impossible. Leucocytosis is usually present, and except in very 
rapidly fatal cases, or in shocked or weakened individuals, it is high (20,000 
to 40,000). The increase affects particularly the polymorphonuclear leuco- 
cytes (see Leucocytosis, page 106). 

Diagnosis.— It is evident that other conditions may closely resemble a 
peritonitis in its incipient stage, or that these very conditions are due to a 
beginning peritonitis that subsides spontaneously or as the result of treat- 
ment. Thus, rapid pulse, high temperature, restlessness, tympanites, hic- 
cough, absent or restricted peristalsis, and nausea and vomiting may each be 
entirely independent of peritoneal infection, and may yield to proper symp- 
tomatic treatment. It is only when these symptoms are associated, and 
persistently so, that a diagnosis of peritonitis can be positively made. In 
the advanced stages these symptoms are all present, but any one or a group 
of them may be the first indication of trouble. 

The diagnosis must also be influenced by the nature of and the compli- 
cations attendant on the preceding operation. If the procedure has been 
performed under favorable auspices, with good surroundings and proper 
technic ; if no focus of infection has been invaded, and if there has been no 
intestinal trauma, peritonitis is, of course, unlikely to occur. If, on the 
other hand, a collection of pus has ruptured into the peritoneal cavity ; if an 



678 GYNECOLOGY 

infected area has been invaded by the operator ; if the intestine has been 
traumatized ; if the operation has been prolonged, the amount of traumatism 
great, and the technic faulty, then peritonitis is more to be expected. 

Treatment. — When there is more reason than usual to fear post-operative 
peritonitis, the case should immediately receive such treatment as will tend 
to localize the process, to eliminate the toxins, and to fortify the patient so 
that she may be able to resist the attack. To this end the head of the bed 
should be elevated at once, so as to favor, by gravity, the limitation of the 
condition to the pelvis or to the lower abdominal cavity. Ice-bags should 
be placed over the operative area, enteroclysis started, and the patient 
closely observed. 

If symptoms of peritonitis appear, the treatment should be continued. 
An attempt may be made to relieve the distention by means of enemas, but 
if a simple and a high compound enema an hour apart are not provocative 
of results, there is nothing to be gained and much harm may result from a 
repetition of this treatment. If the pain is severe, if nausea and vomiting are 
pronounced, and if the patient is exceedingly apprehensive, morphine and 
atropin or heroin may be given with advantage. Liquids by the mouth 
must be restricted. Stimulants should be administered hypodermically, the 
main reliance being placed on strychnine, digitalis, and camphor. Whiskey, 
ammonium carbonate, or strong coffee may be given by the bowel. Cham- 
pagne is at times well borne by the stomach. 

The aim of the attendant must be to keep the infection limited by posture 
and the application of cold, and to avoid undue stimulation of the intestine, 
since an increase of peristalsis will almost undoubtedly spread the infection. 
Furthermore, it is of the greatest importance to supply fluids to the body (sodium 
chloride or sodium bicarbonate by enteroclysis) and to stimulate the patient 
in the hope that she may successfully resist the infection and overcome it. 
If the treatment seems to be unavailing and the process tends to grow worse, 
and it becomes evident that general involvement of the peritoneum has come 
about, there is nothing to be gained by an abdominal incision and the insti- 
tution of drainage, for by this time the disease is so fully developed that 
better results are obtained by a continuance of the conservative plan. 

INTESTINAL OBSTRUCTION 

Etiology and Pathology. — Obstruction to the lumen of the intestines 
may be brought about in various ways ; possibly the commonest is by the 
formation of an adhesion, between a loop of the gut and some part of the 
operative area, that constricts or kinks the intestine, or by the incarceration 
or strangulation of a loop of the bowel that has slipped through an opening 
bridged by adhesions. The essential feature of both forms is adhesions. 

Obstruction may also ocur as the result of the twisting of a loop of in- 
testine on its mesentery, or the slipping of a loop through an adventitious 
opening in the omentum or mesentery. Occasionally obstruction is the 
result of a localized constriction of a part of the bowel from some unknown 
cause (dynamic ileus). Another form of so-called obstruction (adynamic 
ileus) is marked by extreme distention of the entire intestinal tract — a 



POST-OPERATIVE COMPLICATIONS 679 

paralysis of the bowel probably due to vasomotor or trophic disturbances, 
but the true nature of which is probably unknown. 

Obstruction of the intestinal lumen may be complete or partial. It is 
rarely complete at first, but many incomplete cases become complete sec- 
ondarily, by reason of swelling and thickening of the intestinal coat 
at the point of constriction incident to secondary peritonitis and inva- 
sion of the intestinal wall, distention of the gut above the obstructed 
point, and kinking. The obstruction to the passage of the gas and faeces 
results in an increase of the peristaltic action of the bowel above the 
obstructed point. This usually serves only to increase the constriction of 
the lumen, and results in distention of the bowel, impairment of its circula- 
tion, and invasion of its walls by bacteria. If a loop of bowel has slipped 
beneath a band of adhesions or a rent in the mesentery or omentum and 
becomes constricted, its circulation may be so completely shut off that it 
rapidly loses its vitality and becomes gangrenous. 

The intestinal contents above the point of obstruction soon become ex- 
tremely toxic, give off a more or less sour, offensive odor, and the intestinal 
walls show hemorrhagic infarcts. After a time invasion of the intestinal 
wall by bacteria becomes so marked that peritonitis ensues. The bowel 
above the site of obstruction becomes more and more distended, until, in an 
effort to empty itself, the peristaltic action of the intestines is reversed, 
and the intestinal contents is driven back into the stomach. 

Intestinal obstruction may develop within a few hours of, or several 
weeks after, an operation. It is usually sudden in onset, and the symptoms 
become rapidly more severe unless the lumen of the intestine is restored by 
operation. Intestinal obstruction is one of the most frequently fatal post- 
operative complications. 

Symptoms. — The symptoms of obstruction are pain, nausea and vomit- 
ing, tympanites, violent peristalsis, and obstipation. (In adynamic ileus 
there is no peristalsis, but the condition is more a paresis than an 
obstruction of the intestine.) The pain is violent, sharp, and agonizing, and 
is usually referred to the affected area, but it may be reflected to a consid- 
erable distance, Obstipation rarely appears at once. As a rule, a stool, 
and possibly the passage of considerable flatus may be secured by means of 
enemas. Nevertheless, the movement is not quite satisfactory in that it is 
not free, and does not relieve the pain or the distention. 

Peristalsis is generally marked — so much so that it may be noticed by 
the patient, and be distinctly heard by the attendants. Nausea and vomiting 
are common symptoms, appearing earlier and being more severe when the 
obstruction is high, and coming on late and being less severe, except in the 
later stage, when the obstruction is low. 

There is usually but little elevation of temperature until the later stages, 
when peritonitis has supervened or the patient has become decidedly toxic. 
Almost from the first the pulse is increased in frequency. As the disease 
progresses, all the symptoms except the pain become intensified. With the 
onset of structural changes in the intestines pain is complained of less and 
less, until finally the patient may express herself as being comfortable. This 
is an ominous symptom and usually indicates a gangrenous condition. In- 



680 GYNECOLOGY 

testinal paresis, absence of peristalsis, and extreme distention follow. The 
vomiting is persistent, and takes the form more of a regurgitation than of 
an actual ejection, being dependent somewhat upon the intake by the mouth 
at first; soon, however, it becomes almost continuous and independent of 
food or drink. Early in the disease the vomitus consists of the fluid taken 
into the stomach mixed with bile and mucus ; later it is made up of the 
acid, sour, foul-smelling contents of the small intestine, and finally of liquid 
fecal matter. 

In the earlier stages of obstruction the mind is clear, and the patient is 
apprehensive regarding her condition. In the later stages the mind is dulled, the 
talk is rambling, and finally, semi-consciousness or stupor supervene. 

Diagnosis. — It is at times difficult to distinguish between intestinal ob- 
struction in the early stages and peritonitis. In the late stages of both con- 
ditions the one is associated with the other, and, of course, no differentia- 
tion can be made. In the early stage of obstruction sharp pain, increased 
peristalsis, abdominal distention, recurrent vomiting, absolute or partial 
constipation, with normal or but slightly elevated temperature and pulse- 
rate, are characteristic. Attempts to move the bowels by enema may be 
partly successful, but are never altogether satisfactory, the distention is un- 
relieved, and the symptoms persist. 

Treatment. — The treatment of intestinal obstruction must be prompt if 
it is to be of any benefit. As soon as the diagnosis is made, surgical inter- 
vention is demanded. If the condition is strongly suspected and palliative 
measures afford no relief, an exploratory operation is justifiable. Since other 
conditions of a much less serious nature may resemble the early stage 
of an obstruction, palliative measures should be employed at first in the 
hope that they will give relief. Thus, enemas may be given to re- 
lieve distention ; lavage may be employed to empty and cleanse the irri- 
table stomach ; hot stupes or poultices may be applied to the abdomen to 
favor the expulsion of gas. In actual obstruction, however, none of these 
measures will give relief, and it is then that surgery must be invoked. 

It can scarcely be too strongly urged that in a suspected case of intes- 
tinal obstruction cathartics must be carefully avoided. Nothing has a more 
unfavorable influence upon an obstructed bowel than the increase in fluid 
contents and the forcible peristalsis occasioned by the use of a cathartic. 
In cases, of suspected obstruction the administration of a purgative will often 
clear up all doubt as to the nature of the lesion, and if the symptoms were 
not due to obstruction, they will disappear as if by magic. Nevertheless, 
under such conditions the patient would ultimately have been relieved with- 
out the aid of a purgative. On the other hand, if an obstruction -had been 
present, the administration of a cathartic, by increasing the injury to the in- 
testine itself, might have rendered the case hopeless. It is evident, there- 
fore, that in cases of suspected obstruction purgatives by the mouth are un- 
necessary and dangerous. 

What surgical procedure should be employed? Nowhere in surgery 
more than in these cases is experience the mother of wisdom. As soon as 
it has been decided that surgical interference is required, all preparations 
for carrying out a rapid abdominal section should be made. All the instru- 



POST-OPERATIVE COMPLICATIONS 681 

ments should be at hand, the needles threaded, and the ligatures ready be- 
fore anaesthesia is begun. Forceps for intestinal anastomosis, Murphy but- 
tons, and Paul's tubes must be provided. 

Nitrous oxide-oxygen, and ether anaesthesia or local anaesthesia should 
be used. If the original incision is clean and in the median line, it may be 
reopened ; otherwise, the new incision may be made to one side of, above, or 
below the original incision. It should be made, by preference, in the median 
line. According to Moynihan, the most distended part of the intestine or 
that directly above the point of constriction, will usually float higher than 
the remainder and be in the median line, so that the loop that first pre- 
sents itself may be caught up and followed for a short distance below and 
above, in an attempt to locate the obstruction. If this plan reveals nothing, 
the hand may be passed to certain points where, from the nature of the 
operation, adhesions would be most likely to have formed, or to those areas, 
as, e.g., the ileocaecal junction and the hernial rings, where obstruction from 
other causes is most prone to occur. Nothing being found, the loop that is 
most distended should again be picked up and followed systematically 
downward until the point of obstruction is discovered. 

As the intestine is followed in this way the portion that has been in- 
spected may be pushed into the upper abdomen, or if distention is so great 
as to render that plan impracticable, the loops of gut should be surrounded 
by gauze pads saturated with hot salt solution. Evisceration should, if 
possible, be avoided. 

After the point of obstruction is located, the existing conditions will 
determine the course to be pursued. The bowel may be in such good con- 
dition that apparently nothing more than the relief of the obstruction will be 
required. On the other hand, it may at once be evident that resection of a 
badly diseased or gangrenous intestine is imperative. Whatever operation 
is contemplated, unless the patient's condition is so alarming that nothing 
beyond an enterostomy dare be attempted, the dilated and distended part of 
the intestine, especially if the obstruction is high, should be emptied by 
means of a glass tube, after the method of Moynihan. 

The bowel should be opened in the center of an area about which a 
circular suture has been introduced. The incision should be made in the 
long axis of the bowel, and the intestine above and below the point clamped 
or compressed so as to prevent the escape of fluids or gas. The free end of 
the glass tube, with a rubber hose attached for drainage, should then be 
introduced, and the suture tied so as effectually to control any tendency to 
leakage from the intestine. The clamps are removed and the tube is then 
pushed further into the intestine, evacuating loop after loop of the bowel as 
it is threaded, so to speak, upon the glass tube. 

After the tube has been covered with as much of the bowel as it will 
hold, the tube may be removed, the opening closed by suture, and the 
process repeated at a higher point. The latter is rarely required, however, 
and should not be attempted if it can be avoided. It is of marked advan- 
tage thus to rid the bowel of the fluid contents, which is often highly toxic 
and exposes the patient to great danger, even though the obstruction is 



682 GYNECOLOGY 

overcome. After emptying the bowel, the resection and anastomosis may 
be. carried out secundum artcm. . 

If the condition of the patient is so grave that any extensive procedure is 
inadvisable, or if, although the immediate obstruction is overcome, it is 
likely to recur, or if so large a part of the intestine is involved in adhe- 
sions that resection would be exceedingly dangerous, one of two plans 
may be adopted : either a short-circuiting operation may be performed 
or Paul's tubes may be introduced for drainage. The first is applicable 
only to cases of obstruction of the small intestine fairly low down ; 
here a rapid lateral anastomosis with clamp and suture or a Murphy button 
applied to the gut above the sigmoid flexure, may be a life-saving measure. 

In extremely desperate cases, with marked distention, when the intes- 
tine is in badly diseased condition and the patient is so weak as to preclude 
any but the most rapid operation, a loop of the bowel may be pulled out of 
the incision and fixed there, the peritoneal cavity being excluded with a 
running catgut suture ; in the course of several hours it may be opened, and 
a Paul's tube inserted into each limb of the loop. This provides drainage if 
any peristaltic activity of the gut remains, and may tide the patient over 
until an operation for the relief of the obstruction and the restoration of the 
integrity of the intestinal canal can be undertaken. 

In cases of dynamic or adynamic ileus but little can be accomplished. 
Neither condition is clearly understood, and those cases that have come 
to operation have usually been unsuccessful. Adynamic ileus is possibly a 
form of paralysis of the intestine due to injury of the motor nerves that 
supply it. This injury is believed in some cases to have been due to exces- 
sive or rough handling of the intestines, as in making a thorough explora- 
tion of the abdomen, or exerting too much pressure upon the bowel with 
gauze pads in walling-ofl an area from the seat of operation. Dynamic 
iieus is a strange condition that in some cases is inexplicable. In some of 
the reported cases the curiously localized contraction of a few inches or 
more of the intestine may have been a post-mortem change. 



ACUTE GASTRIC DILATATION 

Etiology and Pathology. — Acute gastric dilatation is one of the rare com- 
plications following operation. The condition usually occurs after opera- 
tions for disorders of an inflammatory nature, but not necessarily in the 
upper abdomen. There is commonly an obstruction of the duodenum at the 
point where it is crossed by the superior mesenteric artery, so that the con- 
dition has been attributed to a dislocation downward of the stomach with a 
drag on the duodenum. The obstruction is not always primary, but may be 
secondary to a marked relaxation or atony the result of paresis of the gastric 
motor nerves, which gives rise to an enormous dilatation of the stomach and 
a kink in the neighboring duodenum. 

Symptoms. — The symptoms of acute gastric dilatation are extreme dis- 
tention of the upper abdomen, epigastric distress, persistent nausea, pro- 
fuse vomiting, rapid pulse, and prostration. The condition is troublesome, 
■dangerous, and usually persists in spite of treatment. 



POST-OPERATIVE COMPLICATIONS 



683 



Diagnosis. — The diagnosis may be confirmed by passing a stomach- 
tube, when a considerable quantity of gas and fluid will be evacuated. 

Treatment. — The treatment consists in repeated emptying of the stomach 
by means of a stomach-tube, washing with salt or soda solution, leaving a portion 
of the fluid in the stomach, and placing of the patient in the left latero- 
prone or Sims' position. The injection, hypodermically, of extract of 
pituitary gland has been recommended because of its stimulating action on 
the smooth muscle-fibers. 

In the repeated lavage which is necessary it has been found useful to 
pass a duodenal tube with a weighted end into the stomach, fixing the free 
distal end outside of the mouth. The presence of the tube in the cesoph- 





FiG. 499.— Short circuiting for intestinal ob- 
struction, ileo-sigmoidostomy, diagrammatic. 



FlG. 500. — Short circuiting for intestinal ob- 
struction, ileo-colostomy, diagrammatic. 



agus does not give rise to much annoyance, and relieves the patient of the 
disagreeable necessity of repeated passage of the stomach-tube. For the 
same reason it has been suggested that the proximal end of the stomach-tube 
be brought out through the pharynx, posterior nares, and one nostril, and 
fastened in situ. 

BRONCHITIS 

Etiology. — Bronchitis is one of the most frequent pulmonary complica- 
tions that follow operation. It is a common sequel to etherization when the 
patient at the time has a rhinitis, pharyngitis, or tracheitis. In 
order to avoid this complication operations should be postponed, when 
possible, until acute affections of the nose and throat have entirely cleared 
up. Bronchitis may be the result also of prolonged etherization or of ex- 
posure during the operation. 



684 GYNECOLOGY 

Symptoms. — Post-operative bronchitis manifests the same symptoms 
and runs the same course as other forms of bronchitis. The frequent cough, 
the accumulation of mucus in the throat, the increased respiratory rate, etc., 
all tend considerably to increase the post-operative discomfort. 

Treatment. — The treatment of post-operative bronchitis differs in no way 
from the treatment of bronchitis in general. The patient should be placed in the 
Fowler position. Counter-irritation with mustard should be employed, and 
heroin prescribed for the cough. If any other medication is considered 
advisable, Brown's mixture (i to 4 drams) with 5 to 10 grains of am- 
monium chloride, may be added. 

PLEURISY 

Pathology and Treatment. — Well-marked pleurisy following operation 
is usually associated with pneumonia or with an acute exacerbation of a 
tuberculous process. Severe pain in the chest, with a pleuritic friction-rub 
and pyrexia, apparently independent of pneumonia or tuberculous proc- 
esses, is not infrequently observed. These symptoms, as a rule, are promptly 
relieved by strapping and the administration of the salicylates. The con- 
dition subsides within a few days. Miller points out that many of these 
cases are secondary to small hemorrhagic infarcts in the lungs, which result 
from minute emboli ; phlebitis may appear later in the course of 
the convalescence. 

NEPHRITIS 

Etiology and Prophylaxis. — Nephritis as a post-operative complication 
is a rare occurrence when the patient has been properly prepared for opera- 
tion. In order to avoid nephritis, a careful examination of the urine before 
operation and an estimation of the total quantity eliminated should be 
made, and suitable measures instituted to correct any abnormalities. When 
the symptoms of kidney insufficiency persist in spite of treatment, the 
patient should not be given ether or chloroform. Nitrous oxide and oxygen, 
or, preferably, local or spinal anaesthesia, should be employed instead. 

The routine practice of throwing one or two liters of sterile tap water, 
2 per cent, soda bicarbonate solution, or salt solution into the bowel before the 
patient leaves the operating table, or of administering from 8 to 16 ounces 
every three hours, will do much to alleviate the renal irritation which 
ether produces, even in healthy kidneys, and act as a prophylactic. When 
nephritis is especially feared, sodium bicarbonate (2 per cent.) solution or tap 
water should be used instead of salt solution, which is said to be less favor- 
able in its influence. 

In a large proportion of cases casts and albumin may appear in the urine 
during the first twenty-four to thirty-six hours following operation, but this 
may be regarded merely as the result of irritation of the renal structure — 
i.e., a mechanical or chemical irritation, which is transient in character, and 
not a real hazard to the patient. Actual nephritis must be dealt with in the 
customary manner, as when it occurs under other circumstances. 



POST-OPERATIVE COMPLICATIONS 685 

SUPPRESSION OF URINE FROM URETERAL OBSTRUCTION 

Etiology and Symptoms. — In panhysterectomy for cancer or cervical 
myomata, in difficult supravaginal hysteromyomectomies, in hysterectomy 
for densely adherent adnexa, or intraligamentous cysts, the ureters may be 
exposed to the risk of injury. This risk is lessened by constant orientation 
of the ureters during the course of the operation, whether they are actually 
exposed by dissection or not. In spite of these precautions, the surgeon may feel 
anxious about them after operations which have been unusually difficult. 

A diminution in the excretion of urine after operation is to be expected. 
Usually less than 24 ounces are excreted during the first twenty-four hours. 
The decrease in the total amount is less marked when soda bicarbonate or 
salt solution or tap water is given at the close of the operation or immedi- 
ately thereafter. If, in spite of enteroclysis or hypodermoclysis, the excre- 
tion of urine remains much diminished — 1 to 8 ounces in twenty-four hours 
— there are two possibilities, at least ; either suppression of the kidney func- 
tion or an injury or accident that occludes the ureters. 

Diagnosis. — Suppression of the kidney function may be due to a decided fall 
in blood-pressure which sometimes takes place when a large amount of blood 
has been lost during the operation. An estimation of the blood-pressure 
will clear up this point. Suppression of the urinary function from nephritis 
is not likely to be absolute ; the urine which collects in the bladder con- 
tains albumin and casts, and the general symptoms of nephritis (uraemia, 
oedema, changes in the eye-grounds, etc.) are present. When the anuria is 
absolute or nearly so, for more than twenty-four hours, and the associated 
symptoms do not clearly point to a nephritis, it is desirable to determine at 
once whether any injury has been inflicted on the ureters. The only way to 
settle this question is by introducing a cystoscope into the bladder 
and catheterizing the ureters. If, on exposing the ureteral orifices, the 
examiner is rewarded by observing the ejection of urine from each, he 
need look no further unless the question of partial obstruction on one or on 
both sides must be decided. When the orifices are quiet, each ureter should 
be catheterized. 

If the catheter passes easily it signifies that the ureters are patulous ; 
when an obstruction is found on one or both sides, it is almost invariably 
close to the bladder, within 5 cm. of the ureteral orifice. An obstruction 
more than 10 cm. from the bladder may indicate a constricting ligature at 
that point, but it may also be due to a distortion or kinking of the ureter at 
the pelvic brim, which prevents the passage of the smallest catheter. 

Treatment. — If absolute or nearly absolute obstruction is actually present on 
both sides, the only hope for the patient lies in immediate operation. Ureteral 
catheters should be introduced as far as they will go on each side, and the 
incision should be opened under nitrous oxide-oxygen-ether anaesthesia; the 
operative area should be exposed, and the ureters examined. This may be 
facilitated if the catheters are left in situ; furthermore, the ureters may be 
distended above the point of obstruction and thus be readily located by pal- 
pation ; if this is not done, they must be deliberately sought for and dis- 
sected, as in the operation of panhysterectomy. 



686 GYNECOLOGY 

When the point of obstruction is found, the constricting ligatures should 
be removed. If the ureteral wall or sheath has not been injured, this 
maneuver will be sufficient to restore its function. When the wall, or sheath 
has been bruised or torn and necrosis threatens, the ureter should be divided 
above the injured area, the distal end ligated and cauterized, and the 
proximal end implanted into the bladder. If the proximal end will not reach 
the bladder, it should be implanted into the rectum or the sigmoid. 

If the ureter on one side has been easily freed ; if a minimum amount of 
damage has been done and the kidney on that side is in good condition, in 
desperate cases, where haste is urgent, the other ureter may be ligated. 

If both kidneys are involved by accidental ligation, the release of the 
ureters is demanded in order to save the patient's life. In serious cases of 
complete suppression from bilateral ureteral obstruction, lumbar neph- 
rotomy may be performed to tide the patient over for a time. 

Ligation of one ureter, the other remaining undisturbed, with a healthy 
kidney on the good side, does not result in any marked reduction in the 
urinary output nor in symptoms of uraemia. Usually the patient will com- 
plain for several days of a severe pain in the loin of the affected side, with 
tenderness, but without perceptible enlargement of the affected kidney. The 
pain may disappear entirely in the course of a few days, and no subsequent 
symptoms develop, so that the condition may remain unrecognized. 

If occlusion of the ureter is not absolute and the kidney continues to func- 
tionate, the symptoms of pyelitis, hydroureter, and hydronephrosis gradu- 
ally develop, and make the diagnosis clear. 

A ligature passed about the ureter may so injure its sheath and nutrient 
blood supply that gangrene sets in ; the urine escapes and infiltrates the 
tisues, producing a cellulitis with the formation of pus, which discharges 
externally, either through the cervical stump, the vaginal incision, or the 
abdominal incision. This is the most frequently recognized result of liga- 
tion or other injury to the ureters during operation. 

Bilateral ligation or obstruction of the ureters incident to operation is 
fortunately rare, and will continue so if the operator bears constantly in 
mind the exact position of the ureters and guards against injuring them, or, 
if they are necessarily in the operative field, as in panhysterectomy, he ex- 
poses them deliberately to sight and touch (see page 349). 

PHLEBITIS 

Etiology and Pathology. — Phlebitis is one of the most annoying and 
troublesome post-operative complications. It may follow the simplest aseptic 
abdominal section. It rarely, and practically never, occurs after plastic 
operations and those performed by the vaginal route. Its occurrence has 
been ascribed to infection and to injuries (puncture, contusion) of the deep 
epigastric veins, especially in anaemic patients. 

The most frequent causes seem to be injury of the deep epigastric veins 
as the result of forcible or prolonged retraction of the abdominal incision 
(Clark), anaemia, circulatory weakness, and the restriction of motion fol- 
lowing a celiotomy. 



POST-OPERATIVE COMPLICATIONS 687 

Puncture or bruising of the deep epigastric veins may occur during the 
process of making or of closing the abdominal incision. Injury of the pelvic 
veins may give rise to phlebitis of the broad ligament, a condition that is 
often unrecognized. There may or may not be oedema of the lower ex- 
tremities. To all traumatic causes may be added the hemolytic action of 
bacteria ; these usually are so feebly virulent or are present in such small 
numbers as to produce no gross infection. 

Phlebitis is occasionally a precursor of embolism and minute emboli from 
the site of operation may produce pulmonary infarcts and localized patches 
of pneumonia or pleurisy before the symptoms of thrombophlebitis appear 
(see Pleurisy, page 685). Post-operative thrombophlebitis usually affects 
the femoral veins, and is more frequent on the left than on the right side. 
The process apparently begins in the deep epigastric vein, and extends to 
the point of its junction with the femoral vein above Poupart's ligament. 
Here the walls of the vein are more or less fixed by the surrounding fascia, 
and the smaller volume of venous blood being poured into the larger vessel 
from the epigastrics is believed to result in a sort of whirling motion 
[wirbelbewegung) of the blood at this point; the flow of blood is retarded, 
a thrombus forms, the vein becomes partly or wholly occluded, and the 
walls become irritated and inflamed. 

Symptoms. — The earliest symptoms of phlebitis (embolic pleurisy may 
have been observed in the first post-operative days) are rapid pulse, increas- 
ing in periodic waves, and unaccompanied by a corresponding rise in the 
temperature ; later there are slight elevation of temperature, pain and tender- 
ness in the calf or along the course of the femoral vein, and oedema of the 
affected extremity. These symptoms all vary in degree, and occupy a more 
or less prominent place in the symptom-complex. 

Treatment. — The treatment consists in elevating the affected limb and 
in applying ice to the calf and the groin. At a later stage, after the acute 
symptoms have subsided, a fly-blister may be put over the line of the 
femoral vein below Poupart's ligament. The leg should be wrapped in 
cotton and snugly bandaged. Elevation should be maintained until oedema 
over the tibia and about the ankle has subsided. The limb should not be 
used until the induration, tenderness, and oedema have disappeared and the 
temperature and pulse are normal. Massage should be prohibited for from 
four to six weeks afterward. The use of the limb should be gradually in- 
creased, and a recurrence of the symptoms, even in the slightest degree, 
should be regarded as an indication to resume the treatment by rest and 
elevation of the affected limb. 

Before arising in the morning, a snug bandage of flannel or elastic crepe 
should be applied, beginning at the bottom, encircling the foot, and reach- 
ing to the groin. 

As has been stated, phlebitis is one of the most annoying and obstinate 
complications following operation. Even after prolonged rest and careful 
treatment full compensatory collateral circulation may not be established, 
the leg thus remaining more or less disabled, and becoming swollen when 
any unusual exertion is undertaken. 



688 GYNECOLOGY 

PULMONARY EMBOLISM 

Etiology. — Pulmonary embolism is one of the catastrophes that may follow 
any abdominal operation. It occurs particularly after hysterectomy for 
uterine myomata, and is probably explainable by the fact that anaemia 
and circulatory weakness are often found in myoma patients. In a 
large number of instances embolism follows simple appendicectomy or 
salpingo-oophorectomy, so that it is by no means limited to any one type of 
operation. * Altogether it is a rare complication, but it occurs so suddenly, 
often with no warning whatever, in patients who, up to the moment of seiz- 
ure, have undergone an uncomplicated convalescence, that it must always 
be taken into account. The possibility of this complication alone makes the 
prognosis of celiotomy guarded. 

Symptoms. — The symptoms usually come on without the slightest warn- 
ing, or they may be preceded by those of embolic pneumonia, pleurisy, or 
thrombophlebitis ; they consist of sudden dyspnoea, precordial distress, and 
increase of the pulse and the respiratory rate. Death quickly ensues. As a 
rule, pulmonary embolism takes place within a week or ten days after the 
operation — often when the patient sits up or gets out of bed for the first 
time. It is usually rapidly fatal, the embolic clot being of such a size as 
completely to block the pulmonary artery. Embolism may occur shortly 
after operation, within a few hours, or during the first post-operative days. 
Here, too, it may be rapidly fatal, but undoubtedly cases of embolism occur 
at this time in which the emboli are minute and death does not take place ; 
the grave and alarming symptoms gradually subside, and are succeeded by 
those produced by infarcts in the peripheral distribution of the pulmonary 
artery. Miller believes that most cases of post-operative pneumonia are 
embolic in origin. To the sudden symptoms of embolus previously described, 
in the cases not immediately fatal there are added the symptoms of pulmonary 
infarction or embolic pneumonia, mild or severe in type, depending upon the 
size of the area that has been deprived of its blood supply. 

Diagnosis. — In the fatal cases the condition may be mistaken for a rapid 
and profuse internal hemorrhage or an acute dilatation of the heart. Except 
for those occurring within a few hours of operation, these conditions hardly 
require consideration here. Internal hemorrhage is almost never so rapidly 
fatal, even immediately after operation, and certainly never after the tenth 
post-operative day. Acute dilatation of the heart may be suspected if the 
heart was affected at the beginning, and if the operation was prolonged and 
the patient was kept for a long time in the Trendelenburg position. As a rule, 
the symptoms of acute dilatation are not so sudden in onset. The subse- 
quent course of the case will serve to clear up the diagnosis. In fatal cases 
only an autopsy will serve to make the diagnosis positive. 

Prophylactic Treatment. — Thrombosis must, of course, precede embol- 
ism, although in the majority of these cases it gives no evidence of its exist- 
ence, and is limited to the pelvis. Nevertheless, the causes of thrombosis 
must be eliminated in order to guard against embolism. To this end, in all 
celiotomies, care should be exercised lest a vein be contused or punctured. 
When, in spite of care, injury of a vein occurs and is recognized, the 



POST-OPERATIVE COMPLICATIONS 689 

affected area should be excluded from the circulation by ligating the vessel 
on one or both sides of the injured part. 

A high Trendelenburg posture, with flexion of the knees, is to be avoided. 
Forcible and prolonged retraction should be guarded against in order to avoid 
thrombosis in the epigastric vessels. The treatment, after operation, of those pa- 
tients in whom thrombosis and embolism are especially to be feared (i.e., those 
suffering from uterine myoma, anaemia, or circulatory weakness) includes mainte- 
nance of the heart action and blood-pressure by continuous moderate stimu- 
lation, and by active and passive movements of the legs from the very begin- 
ning of convalescence. With these immediate post-operative measures, it is 
advisable to get the patient out of bed a little sooner than in the 
average case. 

POST-OPERATIVE RENAL INFECTION 

Etiology, Pathology, and Treatment. — Obscure and otherwise unac- 
countable elevation of temperature following operation may be due to a 
post-operative renal infection. The condition usually sets in some time after 
the operation, and may be preceded by cystitis or a focus of pus formation, 
such as a suppurating abdominal incision. 

Many of the cases are really hematogenous infections due to the colon 
bacillus. The clinical picture of the milder forms is that of pyelitis, and the 
case responds readily to treatment (see p. 487). 

More severe forms, due to the colon bacillus or the pyogenic cocci, have 
been observed. These are also hematogenous. The kidney is affected by a 
pyelonephritis. Some cases are rapidly fatal, and operative treatment may 
be required (see p. 473). 

SUPPURATION OF THE INCISION 

Etiology. — At the present day suppuration of the incision is rarely encoun- 
tered. It may be caused by infection alone or infection combined with traumatism 
and devitalization of the tissues, imperfect hsemostasis, and accumulation 
of blood in the wound, etc. 

Symptoms. — An active infection will manifest itself by marked pain and 
tenderness in the wound, with an unusual rise of temperature during the first 
post-operative days. Examination of the incision will reveal the usual signs of 
inflammation. Suppuration occurs rapidly. Separation of the margins of 
the incision results in the discharge of pus. 

In the average case no active symptoms occur to direct the attention to 
the wound during the early days of the convalescence ; but toward the end 
of the first week the temperature does not recede to the normal, to remain 
there permanently. About this time the incision may open spontaneously 
and discharge purulent or bloody fluid, or upon examination signs of in- 
flammation and the presence of fluid beneath the skin will at once 
be apparent. 

Treatment. — Free drainage of the suppurative area is essential to rapid heal- 
ing and should be instituted without delay. Great care should be taken to avoid 
44 



690 GYNECOLOGY 

extension of the infection to the deeper layers of the incision. The abscess 
cavity should not be cleansed by syringing, but by gentle pressure and 
sponging with moist pledgets of cotton. All manipulations must be very 
carefully carried out. 

After free drainage is provided the application of heat will tend to 
hasten resolution. Later, granulating surfaces may be stimulated by silver 
nitrate or scarlet salve. Suitable strapping of the borders of the wound will 
hasten union. 

LOCAL INFLAMMATION OR SUPPURATION IN THE PELVIS 

Etiology, Symptoms, and Treatment. — Occasionally, following pelvic oper- 
ations, there will be noted an elevation of temperature that persists beyond 
what may be termed the normal post-operative febrile period. Associated 
with this there may be lower abdominal or pelvic pain and soreness. Bi- 
manual examination reveals the presence of induration and tenderness some- 
where in the pelvis, varying with the nature of the operation and the degree 
of inflammation. The pelvic structures appear to be more or less fixed. 

In many cases the actual condition is a localized peritonitis or cellulitis 
rather than an actual infection. It is the result of traumatism and devital- 
ization of tissue from ligatures, sutures, etc. 

As a rule, the application of heat to the lower abdomen, hot vaginal 
douches, and rest in bed result in a gradual amelioration of the symptoms. 
Occasionally, in the case of a hysterectomy, the symptoms subside sud- 
denly after a discharge of purulent material through the cervix. 

CYSTITIS 

Post-operative cystitis is usually the result of frequent or unclean cathe- 
terization. (For prophylaxis see page 453; for pathology and treatment 
see page 454.) 

POST-OPERATIVE CARDIAC DILATATION 

Simpson has drawn attention to right-sided hypertension and occasional 
dilatation of the heart following operation. This observer reports that 
Wertheim had a death-rate of 4.4 per cent, from acute dilatation alone, 
following abdominal hysterectomy for cancer. 

Etiology. — This post-operative complication is most likely to occur in 
patients who display the usual clinical evidences of a weakened myocardium, 
as well as those in whom the myocardium is believed to have been 
weakened by excessive business or social cares ; hyperthyroidism, long- 
continued or very recent absorption of bacterial toxins (pneumococcus, 
streptococcus, diphtheria bacillus, etc.) ; biliary poisons; toxins from malig- 
nant neoplasms ; marked or chronic anaemia, etc. 

Prolonged anaesthesia, the Trendelenburg position, and the injection of 
large quantities of salt solution increase the burden of the heart and favor 
the occurrence of cardiac dilatation. 

Symptoms. — The clinical picture of hypertension or beginning cardiac 
dilatation shows : An abrupt increase of the pulse-rate — 20 or more beats — 



POST-OPERATIVE COMPLICATIONS 691 

slight cyanosis, sudden marked weakness, great apprehension, and an in- 
creased area of the right heart. 

Treatment. — The treatment consists in elevating the head of the bed, the 
administration of morphine by hypodermic injection, and the cautious use of 
cardiac stimulants. 

POST-OPERATIVE PAROTITIS 

Parotitis may occur as an occasional complication during operative 
convalescence, usually appearing within the first week or ten days following 
operation. It occurs with much greater frequency (one observer claiming 
it appears ten times as often) after operations on the pelvic or abdominal 
viscera than following operations on other parts of the body. The condi- 
tion may occur as a sequel to septic abortion. Post-operative parotitis is 
usually unilateral. Less than half of the cases develop suppuration. 

Etiology. — While a close glandular and sympathetic relationship exists be- 
tween the parotid gland and the pelvic organs, as is evidenced by the ovaritis that 
developes during the course of mumps, and the increased salivary secretion 
of early pregnancy and menstruation, it is unlikely that this plays any part 
in the etiology. In most cases of post-operative parotitis the infecting 
agent has its origin in some septic condition of the mouth or upper air- 
passages, as, for example, carious teeth, Vincent's angina, pyorrhoea, sordes, 
and other evidences of faulty oral hygiene, infected tonsils and adenoids, 
and chronic posterior rhinitis and pharyngitis. In the majority of cases 
some of these findings have been noted, and the infecting organism is be- 
lieved to gain access to the gland by passing up Stenson's duct. The 
staphylococcus pyogenes aureus has been found more frequently than any 
other organism in the pus of post-operative parotid abscess. 

The conditions favoring the development of parotitis are the dry condi- 
tion of the mouth induced by the anaesthetic, as well as the nervous influ- 
ences that affect the secretions, the lowered intake of water, the removal 
of fluid from the body due to vomiting, and the mechanical insult to the 
tissues by swabbing the mouth during anesthetization. The fact, too, that 
of the three salivary glands the parotid is the only one supplied with lym- 
phatics may have a part in favoring the development of this condition. 

Symptoms. — The infection is recognized by a reddened and painful 
swelling in the parotid region, accompanied by fever, and rarely chills, de- 
veloping a few days after operation. The swelling may subside under treat- 
ment or go on to the formation of an abscess, with characteristic symptoms. 

Treatment. — Treatment begins with prophylaxis. Carious teeth should be ex- 
tracted, infected tonsils removed, pyorrhoea and other manifestations of oral and 
nasal sepsis treated. These cavities should be brought to the highest degree 
of surgical cleanliness by the use of the tooth-brush, mouth-washes, and 
nasal irrigations of weak potassium permanganate (i : io s ooo) or other suit- 
able antiseptic solutions. 

The body should be well supplied with fluids both before and after opera- 
tion, and during anesthetization intraoral manipulation should be avoided 
as much as possible. 



692 GYNECOLOGY 

Should parotitis develope, it may be successfully combated by con- 
tinued use of the mouth-washes in order to favor drainage from the gland, 
and the local application of compresses wet with cold solutions, such as 
saturated boric acid, i per cent, aluminum acetate, or I : 5000 mercury 
bichloride. An ice-collar may be applied to the gland. Stimulating oint- 
ments, such as 10 to 25 per cent, ichthyol or isarol, may be applied, or the 
gland may be painted with tincture of iodine. 

If an abscess forms, it should be opened by a free incision, the pus 
evacuated, the cavity irrigated and packed with narrow strips of gauze impreg- 
nated with 2 per cent. dichloramine-T, with proper renewal of dressings. 

ACIDOSIS 

Etiology. — All alkaline bases that are left after the non-volatile acids have 
been neutralized are converted into bicarbonate, and since the bicarbonate con- 
tent of the blood in the normal individual is constant, any decrease in the 
alkalinity may be regarded as an acidosis. 

Acidosis is due either to the incomplete combustion of fat with the for- 
mation of ketone bodies, beta-oxybutyric acid, diacetic acid, and acetone, or 
to the failure of the kidneys to eliminate the acids normally eliminated by 
them. In acidosis due to the first cause the ketones appear in the blood and 
urine, and the breath takes on an aromatic odor. 

Symptoms. — Frequently a mild acidosis may exist without evincing symp- 
toms. If, however, the acidosis becomes more severe, the patient will exhibit a 
symptom-complex such as the following : A peculiar hyperpnoea without cyanosis 
(air hunger) ; vomiting ; headache ; acetone and diacetic acid in the urine if 
the acidosis follows anaesthesia, diabetes mellitus, or starvation, but not if 
the acidosis is due to renal disease ; aromatic odor on the breath in the cases 
exhibiting ketones in the urine. 

Diagnosis. — In order to make a diagnosis of acidosis a number of methods 
are available. In the first place, the condition may be suspected if the symptom- 
complex of acid intoxication just described, with its peculiar respiration, 
vomiting, and headache, is present. To base the diagnosis on this finding 
alone, will, however, lead to a considerable percentage of error, for in a 
certain number of cases further investigation by special methods has re- 
peatedly failed to confirm it. When, however, in conjunction with the char- 
acteristic symptom-complex, acetone and diacetic acid are found in the 
urine, the diagnosis is much more justifiable. It must be remembered that: 
acetone and diacetic acid appear in the urine in many mild cases of acidosis, . 
and has no bearing on the prognosis. This is especially frequent in chil- 
dren. Thus, Holt has found acetonuria in 70 per cent, of the pneumonias 
of children. For the recognition of and to insure the more accurate diag- 
nosis of all forms of acidosis, one of the newer methods now available, such 
as the Van Slyke method for determining the bicarbonate content of the 
blood, or the Marriot, Fredericia, or Plesh-Higgins method for determining 
the alveolar C0 2 tension of the expired air, should be employed. One of 
these methods ought to form part of the equipment of every hospital labora- 
tory for routine use in the study of all patients in whom acidosis may be 



I 



POST-OPERATIVE COMPLICATIONS 693 

suspected or, indeed, until we have acquired further knowledge of this sub- 
ject. The Marriot method is very simple, and can be carried out in a few 
minutes in the physician's office as well as in the hospital ward. The Van 
Slyke method can be conducted in any well-developed hospital laboratory, 
and does not require any special cooperation on the part of the patient. The 
methods for determining the C0 2 tension of the alveolar air may give incor- 
rect results if the patient has an irritable respiratory center or if a pathologic 
pulmonary condition is present, or one that will cause too rapid or 
embarrassed breathing. 

For routine use the methods just mentioned are the best. Other methods 
that are available are the hydrogen ion determination of concentration in 
the urine and blood ; also the quantitative determination of the ketone bodies 
in the urine and blood, and finally the method for ascertaining the ammonia 
content of the urine in cases in which there is a ketonuria. These last de- 
scribed methods are valuable if they can be carried out in conjunction with 
the first-mentioned methods, since they tend to make the study of the case 
more thorough. 

Treatment. — The treatment is largely prophylactic. All operative cases 
should be examined for acetone and diacetic acid, and where these are 
found, the degree of acidosis should be determined and treatment should be 
directed accordingly. When there is apparent a predisposition to acidosis, 
immediately after operation sodium bicarbonate (2 per cent.) and glucose (5 
per cent.) solution should be given per rectum by means of continued or 
interrupted enteroclysis. 

In the treatment of post-operative acidosis, if there is no contraindica- 
tion from a surgical standpoint, the gastro-intestinal tract should be cleared 
by the administration of castor-oil and enemas. Diuresis should be pro- 
moted in cases of renal or cardiorenal deficiency. Sodium bicarbonate 
should be given by mouth, by rectum in 2 to 5 per cent, solution, or in- 
travenously, 1 to 2 per cent. (500 to 1000 c.c). Glucose may be exhibited 
by the mouth or given in 5 to 10 per cent, solution by the rectum, or 
Kahlbaum's dextrose may be injected intravenously (2.5 per cent.) in nor- 
mal salt solution. The dose should be regulated by observing the effect of 
the remedy on the reaction of the urine. The urinary fluid should be ren- 
dered neutral, but not distinctly alkaline. 1 

BIBLIOGRAPHY 

Axders, J. M. : " Ether Pneumonia." University Med. Mag., Phila., 1897. 
Axspach, B. M. : " Enterostomy and Enterocolostomy in the Treatment of Acute Intes- 
tinal Obstruction Following Pelvic Operations." Jour. Amer. Med. Assoc, 1918. 
Austin, J. H. : " Acidosis." Penn. Med. Jour., 1916-17, xx, 356. 

1 Farrar has recently reviewed the chemical constituents of the blood and their relation 
to lung ventilation in health. She notes the importance of the bicarbonates in the blood as 
constituting the alkali reserve in the body, and the standard C0 2 combining power of the 
blood plasma in women. There is a fall in the alkali reserve during operation, and this 
bears a certain relation to the blood pressure and respiration. There is a certain incidence 
of acute acidosis in operation, and it has considerable importance as a factor in shock. 

Farrar reports a series of cases at the Woman's Hospital in New York, which were 
treated during operation with glucose (20 per cent.) and gum acacia (6 per cent.) given 
intravenously, and shows their value in maintaining blood pressure, nitrition, and diuresis. 



I 



694 GYNECOLOGY 

Baisch, K. : " Die Prophylaxe der post-operativen Cystitis." Munch, med. Wochenschr., 
1903, No. 38, 1628 ; Ibid. : " Erf olge in der prophylaktischen Bekampfung des post- 
operativen Cystitis." Cent. f. Gynak., 1904, Bd. lxxviii. 

Baldy, J. M. : " The Mortality in Operations Upon Fibroid Tumors of the Uterus." Amer. 
Jour. Obst, 1905, Hi. 

Bonney : " The After-treatment and Post-operative Complications of Coeliotomy for 
Pelvic Disease in Women." Lancet, London, 1899. 

Bovee, J. W. : "The Influence of the Trendelenburg Position in the Quantity of Urine 
Excreted During Anaesthesia." Trans. Amer. Gyn. Soc, 1910, 443. 

Clark, J. G. : " Etiology of Post-operative Femoral Thrombophlebitis." Univ. of Penna. 
Med. Bulletin, July, 1902. 

Collins, G. H. : " Parotitis as a Post-operative Complication." Surg., Gynec. and Obstet., 
1 91 9, xxvii, 404. 

Dyball: "Parotitis Following Injury or Disease of the Abdominal and Pelvic Viscera." 
Annals of Surgery, Phila., 1904. 

Fakrar, Dr. Lilian K. P. : " Acidosis in Operative Surgery and Its Treatment by Glucose 
and Gum Acacia Given Intravenously." Trans, of Amer. Gyn. Soc, 1920. 

Furniss : " Post-operative Renal Infection." Trans. Sect. O. G. and A. S., A. M. A., 

1913, 49- 

Gatch : " The Effect of Laparotomy Upon Circulation." Trans. Amer. Gyn. Soc, 1914, 
xxxix, 180. 

Gebele : " Uber embolische Lungen-Affektionen nach Bauch-operationen." Beitr. z. klin. 
Chir., Bd. xliii. 

Gerulanos : " Lungen Complicationen nach operativen Eingriffen." Deutsch. Zeitsch. f . 
Chir., Leipzig, 1900. 

Holscher : " Experimentelle Untersuchungen uber die Entstehung der Erkrankungen 
der Luftwege nach Aethernarkose." Archiv f. klin. Chir. ; Bd. lvii. 

Hurd : " Post-operative Insanities and Undetected Tendencies to Mental Disease." Amer. 
Jour. Obst., N. Y., 1899. 

Kelly, H. A. : " Post-operative Psychoses." Trans. Amer. Gyn. Soc, 1909, 426. 

Kelly, Jas. A. : " Acid Intoxication : Its Significance in Surgical Conditions." Annals of 
Surgery, Phila., 1905, xli, 161-200. 

Manton, W. P. : " Parotitis Following Induced Abortion in a Case of Pernicious Vomit- 
ing of Pregnancy." Trans. Sect. O. G. and A. S., A. M. A., 1918, 146. 

Mikulicz, von : " Pneumonic" Centralbl. f. Chir., 1901, No. 29. 

Miller, G. B. : " Complications Following Operations." Kelly-Noble, Gynecology, chap, 
xxvi, ii, Phila., Saunders, 1907 ; Ibid. : " Post-operative Thrombosis and Embolism." 
Amer. Jour. Obst., 1907, lvi, No. 3, 347. 

Moynihan, B. G. A. : Abdominal Operations, 2905, W. B. Saunders & Co., Phila. and 
London. 

Neugebauer, von : " 87 neue Beobachtungen von zufalliger Zuriicklassung eines Sub- 
operatione benutzten Fremdkorpers in der Bauchhohle, etc." Zent. f. Gynak., 
Leipzig, 1904. 

Olshausen : " Uber eine bisher unerkannte Todesursache nach Laparotomien mit Eventra- 
tion der Darmschlingen." Zeitsch. f. G. u. G., Leipzig, 1888, xii, 238-241. 

Polak, J. O. : " Acute Gastric Dilatation as a Post-operative Complication." Trans. Amer. 
Gyn. Soc, 1909, xxxiv, 466 ; Ibid. : " A Clinical Study of Blood-Pressure, Pulse-Pres- 
sure and Hemoglobin Estimations, in Post-operative Shock, Hemorrhage and Cardiac 
Dilatation." Trans. Amer. Gyn. Soc, 1917, xlii, 583; Ibid. : "The Conduct of Gyneco- 
logical and Obstetrical Operations in the Presence of Acute and Chronic Endocarditis." 
Trans. Amer. Gyn. Soc, 1913, No. 38. 

Schenck : " Thrombosis and Embolism Following Operation and Childbirth." Trans. 
Amer. Gyn. Soc> 1913, xxxviii, 295. 

Simpson, F. F. : " Post-operative Complications Involving the Alimentary Tract." Amer. 
Jour. Obst., 1907, lvi, No. 3, 332; Ibid.: "Right-sided Hypertension with Occasional 
Cardiac Dilatation as Post-operative Complications." Trans. Sec. Obst., Gyn., and 
Abdom. Surgery, A. M. A., 1913. 

Taussig, F. L. : " Bladder Function After Confinement and After Gynecological Opera- 
tions." S., G. and O., 1915, xxi, 416; also in Trans. Amer. Gyn. Soc, 1915, No. 40, 351. 

Thomson and Kemp: "Experimental Researches on the Effects of Different Anaes- 
thetics," Med. Rec, N. Y., 1898. 



POST-OPERATIVE COMPLICATIONS 695 

Tracy, S. E. : "A Simple and Efficient Means of Applying Artificial Heat." Jour. Amer. 

Med. Assoc, October 22, 1910, 144. 
Veit, J.: "Die Prophylaxe der Embolie nach gynakologischen Operationen." Zentralblatt 

f. Gynakologie, 1910, xxxiv, No. 1, 1. 
Ward, G. G. : " Post-operative Renal Infection." Trans. Amer. Gyn. Soc, 1915, xl, 337. 
Weibel, M. : " Weitere Beobachtungen iiber das Verhalten der Ureteren nach der erwei- 

terten abdominalen Karzinomoperation." Zeits. f. Gyn. u. Urol., 1913, iv, 138. 
Welsh : Albutt's System of Medicine, 1898. 



CHAPTER XXXIX 
MECHANICAL AND MEDICINAL AIDS TO TREATMENT 

ABDOMINAL SUPPORT: BINDERS AND BANDAGES 

Abdominal binders are used for the purpose of lending support to 
the abdominal walls in cases of pendulous abdomen, diastases of the rectus 
muscles, umbilical hernia, floating kidney, gastroptosis or visceroptosis, 
sacroiliac sprain, and recent celiotomy incisions. 

After abdominal section an abdominal bandage does little actually to 
prevent the formation of a hernia, but it tends to remind the patient of her 
late experience and affords a certain amount of protection to the scar, 
which at this time is not so firm and strong as it subsequently becomes. 
Such bandages should be very simple ones, and may be discarded after two 
or three months, unless the patient is extremely stout or has a pendulous 
abdomen, when the support afforded by a corset or a binder should 
be continued. 

In cases of pendulous abdomen, general visceroptosis, floating kidney, 
or separation of the recti, a properly fitting corset 1 will, in the majority of 
instances, be more comfortable and more effectual than a binder. The 
corset should be designed especially for this purpose, and should be made 
in one piece. When properly fitted and applied, the support given to the 
abdomen by such a corset comes not directly from in front, but from below 
and in front, and in that way the entire lower abdomen is supported (see 
Figs. 450, 45!>and 501). _ 

The patient should lie in the recumbent position while putting on her 
corset. The corset should fit the lower abdomen snugly, and it should exert 
no constriction or pressure about the waist-line and the epigastrium. 

Corsets may be designated as neutral, bad and good. The majority of corsets are 
neutral, that is, they are of such construction, and worn so loosely that they affect the 
carriage in no important manner. The features of the bad corset are: 1. They are long- 
behind (especially at the top) and short in front (especially at the bottom). 2. They are 
cut to exert their greatest pressure at the waist. 3. They have strongly marked sacral 
curves, and are highly incurved at the waist in front. 

The features of the good corset are : 1. They lace in front. 2. They reach to the 
level of the trochanters. 3. They are not high enough in front to touch the breasts. 4. 
They fit tightly around the pelvis (especially in the space between the iliac crests and 
the trochanters, and decrease regularly in the pressure which they exert from the lower 
to the upper edge. 5. They are slightly incurved at the waist line at the back and sides, 
but show no waist curve in front. 

Briefly, so far as posture is concerned, the bad corset throws the center of gravity 
forward; the good corset holds it in its proper position. In addition to its effect on 
equilibrium, the bad corset constricts the waist, depresses the lower abdomen, and affords 
no support to the pelvis or the sacroiliac articulation. The good corset, in addition to 
maintaining correct equilibrium, supports the pelvis, sacroiliac joint, and lower abdomen, 
and exerts no constriction at the waist. The correction of the equilibrium may be 
graphically determined by the change in the posterior and anterior outlines of the body. 
(Reynolds and Lovett. Dickinson.) 
696 



MECHANICAL AND MEDICINAL AIDS TO TREATMENT 697 

There are a number of binders on the market which in some cases — for 
example, very obese women and those who are not accustomed to wearing 
corsets — will be more satisfactory than a corset. Such a binder supports 
the abdomen from below, is attached to the garters that hold it in place, 
does not contain any whalebone, rubber, or leather, and may be washed 
without injury. 

In some cases of nephroptosis a pad may be attached to the corset in 
such a position that when adjusted it lends additional support to the kidney. 
In the average case the kidney pad is not required. In cases of ventral or 
umbilical hernia a specially devised pad of hard rubber may be attached to 
the binder or corset. In cases of sacroiliac sprain, static backache, etc., a 
steel brace or an inner reinforcing belt may be attached to the corset. 




Fig. soi. — Abdominal binder for post- 
operative use. (Storm.) 



LOCAL APPLICATIONS 

To the Endometrium. — Not many years ago the accepted method of 
treatment for patients who had a discharge from the uterus con- 
sisted in making intrauterine application of 
disinfecting solutions. At the present day, 
with the perfection of operating technic, in- 
creasing accuracy in diagnosis, etc., it has 
become recognized that applications to the 
endometrium are rarely indicated, except in 
connection with instrumental dilatation and 
curettement of the uterine cavity. 

During the acute stage of an infection all local 
treatment is harmful, and in the chronic stage there 
are almost invariably present lesions of the adnexa 
that forbid intrauterine applications except in 
connection with other operative treatment. 

It is quite difficult, moreover, to make an application to the endometrium 
with any degree of thoroughness or uniformity unless the patient is anaes- 
thetized and the cervical canal is thoroughly dilated. The truth of this 
statement can easily be appreciated if one remembers the shape of the uterine 
cavity and the difficulty experienced in passing a sound through the undilated 
cervix m an unanaesthetized subject. Even if it were possible to pass a 
sound wrapped with cotton, the solution in the cotton will be expressed 
long before the sound reaches the endometrium. 

Various forms of intrauterine syringes for the purpose of injecting solu- 
tions have been devised, but all must be used with caution. When the 
endometrial cavity is filled under pressure, some of the fluid may escape into 
the tubes or even into the peritoneal cavity. To prevent such a disaster, 
the cervical canal must not be obstructed at the moment of injection, and 
only a small and limited amount of solution must be used at a time. A form 
of syringe that renders injection safe is one fitted with a long nozzle, the 
end of which is roughened and contains lateral perforations. This nozzle 
is wrapped with sterile cotton and introduced into the endometrial cavity ; 
the solution is then injected into the cotton and brought into contact with 



698 GYNECOLOGY 

all parts of the endometrium. Even this is quite unsatisfactory without the 
aid of general anaesthesia and full dilatation of the cervix ; when these condi- 
tions exist, it is advisable to curette the uterus and wash out the blood and 
endometrial debris with a two-way catheter before making the application. 
The solution that is best adapted for intrauterine application is tincture 
o^ iodine. Others that have been recommended are alcohol, 95 per cent. ; 
argyrol, 25 per cent. ; silver nitrate, 10 per cent, (followed by salt solution) ; 
formalin, 1 per cent., etc. 

To the Cervix. — Applications to the cervix are frequently made for the 
purpose of treating a cervical leucorrhcea. Such a discharge may be due 
to primary infection by the gonococcus, or it may simply be a hypersecre- 
tion of the cervical glands when the cervical lips have been everted by 
laceration and the cervical mucosa has been exposed to various forms of 
trauma. In either event applications are not entirely satisfactory. It k 
difficult to apply a distinfecting solution to the entire cervical canal with- 
out overstepping its boundaries and encroaching upon the endometrium. 
Moreover, the cervical mucosa is so rich in folds and is covered by so 
thick and tenacious a mucus that it is exceedingly difficult to reach the 
bottom of these folds and get at the nidus of infection. 

It is evident that no application will cure a cervical discharge that is due 
to an eversion of the cervical mucosa and mechanical irritation. The most 
that can be done under such conditions is to hold the symptoms in abeyance. 

Before the application of a disinfectant an effort should be made to re- 
move the thick mucus ; this is often almost impossible to accomplish with 
any satisfaction. Various solutions have been employed for the purpose, 
such as alcohol, silver nitrate, and dilute alkaline solutions of various kinds. 
After the mucus has been removed the disinfecting solution may be applied 
by means of a cotton applicator, care being taken to reach all parts of the 
cervical canal but not to go beyond the internal os. The difficulty of deter- 
mining just when the instrument has reached the internal os may be appre- 
ciated at once. 

The most effectual method of destroying a cervical infection is by means 
of the actual cautery (see page 704). 

Cervical infections may also be influenced by the introduction and appli- 
cation of glycerine tampons to the external os and the use of prolonged hot 
douching; dilatation of the external os may be of service where the orifice 
is narrow and the pus is retained within the canal. 

To the Vagina. — Applications to the vagina may be made directly 
through a bivalve speculum (see Fig. 502) with a cotton-wound applicator, the 
mucosa being cleansed with cotton before the solution is applied. In certain 
cases the therapeutic solution may be simply poured into a tubular or a 
bivalve speculum while the patient lies in the dorsal position with the hips 
elevated; the excess of solution is removed with cotton. Applications cf 
disinfecting solutions to the vaginal mucosa should be supplemented with 
vaginal tampons. 

To Bartholin's Glands. — Applications to Bartholin's glands or ducts can 
be made with a fair degree of satisfaction by means of a hypodermic needle 



MECHANICAL AND MEDICINAL AIDS TO TREATMENT 699 




Fig. 502. — Bivalve and Sims' specula introduced. (Anspach, in Hare & Landis' Modern Treatment, Lea 
& Febiger.) Patient in the dorsal andin the Sims' position; exposure of cervix and vaginal vault for 

inspection and treatment. 



700 GYNECOLOGY 

with a blunt point. The needle is guided into the duct as far as it will go, 
and a few drops of the fluid are expressed under pressure. 

To the Urethra and Skene's Tubules. — Application to the urethra may 
be made by means of a small cylinder of cotton wrapped upon an applicator, 
which is passed into the urethra and then detached from the applicator and 
allowed to remain. Applications to Skene's tubules may be made with a 
blunt hypodermic needle. The technic of these applications has been de- 
scribed on pages 441 and 444. 

THE USE OF HEAT IN THE TREATMENT OF PELVIC INFLAMMATORY DISEASES 

For the local application of heat in pelvic inflammatory cases Gelhorn de- 
vised a hot-air apparatus that may easily be constructed and is not expen- 
sive. The heat can be very effectually applied without discomfort, and the 
degree of heat can easily be regulated. 1 

The mode of application is exceedingly simple. The apparatus, with the 
thermometer carefully adjusted, is placed over the exposed abdomen, and 
the electric light is turned on. It is preferable that the heat be increased 
gradually, and for this purpose the apparatus is not covered with blankets 
until after a few moments' exposure. The degree of heat obtained can be 
noted at any time, and may be reduced or increased at will. While the 
temperature can be easily raised to 300 , from 200 to 220° seems the most 
suitable temperature ; with eight 16-candle-power bulbs this degree is 
reached within from fifteen to twenty minutes. As the reaction to the treat- 
ment may vary in the individual case, patients should not be left alone, and 
the pulse should be watched carefully. A cold cloth is placed on the fore- 
head of the patient, and she is urged to drink cool water freely. 

The patients, at first, feel quite comfortable. In about ten minutes, 
however, when the temperature reaches 180 , they frequently complain of 
intense burning. It is imperative, then, to discontinue the treatment for 
the time being. The sensitiveness decreases with each application, so that 
after a few days the baking process may be continued for one-half hour or 
even longer, the temperature being raised to 220 . The patients perspire 

1 Gelhorn's apparatus consists of two semi-circular cradles made of thin sheet- 
iron and covered on the inside with asbestos. These two cradles fit over each other 
and may be pulled apart, after the fashion of a telescope. Electric-light bulbs, eight 
in number, are attached to the inside of the free edges, and there is a long, suitable 
attachment for the nearest socket. In the convexity of the cradle a hole is provided 
for a thermometer. The mercury bulb of the latter should be only about two or 
three inches above the abdomen, so as to register the actual temperature of the 
immediate surroundings and not the temperature of the air in the upper portion of 
the chamber, which naturally is warmer than in the lower portion. If no thermometer 
is used, this hole may serve as a chimney through which the hot, moist air can escape. 
A number of hooks are present, from which gauze bags filled with calcium chloride 
may be suspended, in order to absorb any excess of moisture within the air chamber. 

This apparatus has many advantages. It is light, portable, and clean. There is 
no danger from fire, although care must be taken to prevent the calcium bags from 
touching the electric bulbs, lest they explode. The heat can easily be regulated by 
eliminating one or more bulbs, thus avoiding burns of the skin. By changing the 
candle-power of the bulbs any desired degree of heat may be obtained. By pulling 
the cradles apart a larger portion of the body, or even the entire body, according to 
the indication, can be heated. Convenient electro-thermic heating apparatus — 
adapted to the pelvis — is now on the market. 



MECHANICAL AND MEDICINAL AIDS TO TREATMENT 701 



freely over the entire body, especially on the abdomen. The exposed skin 
becomes an intense red, either diffuse or in more circumscribed areas. 

The immediate effects of the treatment consist in a marked decrease of 
pain and improved appetite, and large quantities of water can be taken. Many 
women gain in weight, and constipation is relieved. Some experience a 
pleasant sensation of relaxation and fall into a refreshing sleep. Burns of 
a mild degree may occur, but with proper precautions can be avoided. 
Gelhorn has observed 
small blisters in two 
cases only, and in these 
there was profuse per- 
spiration and the skin 
had not been wiped off 
promptly. 

There is no absolute 
rule as regards the dura- 
tion of the treatment or 
the degree of heat that 
should be used. It is 
best to go slowly, and 
the temperature should 
never be increased when 
the patient complains of 
heat. After the treat- 
ment the patient should 
be permitted to cool 
gradually, remaining in 
the apparatus for one- 
half hour or being 
wrapped in warm blan- 
kets. A cool sponge-bath 
may be given directly 
after the treatment. 

The principal indica- 
tions for this treatment 
are found in chronic in- 
flammatory lesions of 
the pelvis. It should not 
be used while the patient 
shows any elevation of temperature, and if an elevation of temperature follows its 
use, the treatment should be suspended. The number of treatments re- 
quired in individual cases varies from eight to thirty-five. 




Fig. 503. 



-Smith pessary; the form most frequently used in the treat- 
ment of retroversion. 




Fig. 504. — Hodge pessary; has a slightly concave upper bar with less 

marked upper curve and a broader lower bar than the Smith pessary, 

useful when the posterior vaginal vault is shallow and the perineum 

is relaxed. 



ELECTRICITY 

The use of electrotherapy in gynecology is more or less in disrepute, 
and in recent years it has probably fallen into disuse among reliable 
practitioners. Under certain conditions and in some affections its use 
may be justified. The negative pole of the galvanic current is occasion- 



702 



GYNECOLOGY 




ally an effectual treatment for amenorrhea. An ill-developed uterus is 
said by some authorities to have been increased in size as the result of the 
use of intrauterine galvanism or faradism. 

In employing intrauterine electric treatment great care must be taken 

to sterilize the vaginal canal 
and the electrode. The elec- 
trodes must be boiled. The 
cervix should be exposed 
through a bivalve speculum, 
the os cleansed with cotton, 
moistened with a weak bi- 
chloride solution, and the 
sterile electrodes should be 
passed directly into the 
uterine cavity without touch- 
ing anything but the cervix. 
A large, flat, moist electrode 
should be placed externally 
upon the abdomen. 

PESSARIES 

The pessary that is most 
useful in the treatment of re- 
troversion is that devised by 
Smith (see page 250). The 
Smith pessary may be used 
also in descensus and in 
slight degrees of prolapse in 
younger women during the 
reproductive period. When 
the pessary is not satisfactory 
in such cases, operation should 
be advised (see page 613). 

Most cases of prolapse are 
seen in women past the meno- 
pause, and here the ring 
pessary is the one of 
choice. A ring pessary is held 
in place by the lateral attach- 
ments of the vagina, and is 
supported to a certain extent 
by the rami of the pubes. A 
hard- or a soft-rubber ring pessary, a hard-rubber disk pessary, or a Menge 
pessary, according to the varying conditions of the case, will be indicated. 
In mild cases, when the vaginal introitus is not contracted and the vaginal 
walls are not excessively redundant, a hard-rubber ring pessary may be 
used. When the vaginal introitus is of such size that a pessary large 
enough to distend the vaginal fornices could not be passed through it with- 



Fig. 505. — Soft-rubber ring pessary; useful in descensus in 
elderly women with narrow vaginal orifice. 




Fig. 506. 



-Disk pessary; useful in elderly women with descensus 
and marked cystocele. 



MECHANICAL AND MEDICINAL AIDS TO TREATMENT 703 



out causing great pain, a soft-rubber one should be substituted. This may 
be compressed during its introduction through the vaginal orifice. 

When the anterior vaginal wall especially is redundant and has a ten- 
dency to prolapse 
through the central 
opening of a ring pes- 
sary, a disk pessary (Fig. 
506), which affords a 
larger base of support, 
may be used. 

Menge has modified 
the ring pessary by at- 
taching to it a sort of 
rudder that holds the 
pessary with its plane 
transverse to the long 
axis of the vagina (see 
Figs. 286, 507, and 508). 
Altogether this is the 
most satisfactory form 
of pessary for use in 
prolapse case.s. 

Certain principles must 
be observed in the use of 
a pessary in order to in- 
sure its success. A pessary must never be employed for the purpose of 
exerting pressure ; if this is necessary in order to hold the uterus in a 




Fig. 507. — Menge pessary (assembled); useful in prolapsus in elderly- 
women. 





**•- 



Fig. 508. — Menge pessary (with stem detached). 



proper position, then pessary treatment is not indicated. Adnexal diseases 
contraindicate the use of a pessary. 

The pessary should always be carefully selected and fitted for the indi- 



704 



GYNECOLOGY 



vidual case. It should be removed every four to six weeks for cleansing, in 
order to prevent any irritation or soreness of the vaginal walls with which 
it comes in contact. It should be left out for a few days and then replaced. 




Fig. 509. — Intrauterine douche nozzle. Bozeman-Fritsch model. 

If douches are required, they should be made of sterile water with a liquid 
antiseptic only. Douche powders should not be used, thus avoiding the 
deposition of salty incrustations on' the pessary. 

THE ELECTROCAUTERY AND THE THERMOCAUTERY 

Hunner has used the cautery especially in the treatment of cervical infections, 
his method being to make radical strokes into the mucosa to a depth of nearly 







Fig. 510. — Vaginal vault packed with tampons. (Anspach, in 
Hare & Landis' Modern Treatment, Lea & Febiger.) 

i cm. He uses this method in office practice, and claims to have had considerable 
success with it. The only objection to the method is the fact that it is followed by 
sloughing, with its consequent danger and annoyance to the patient. In 



MECHANICAL AND MEDICINAL AIDS TO TREATMENT 705 

most cases in which its use would be indicated a surgical operation would 
be preferable, but if the patient has a decided objection to surgical meas- 
ures, the cautery may be employed (see Hunner's original paper for technic). 

THE UTERINE PACK 

The use of an intrauterine tampon is very rarely required except 
in connection with some form of operative treatment, as, for example, 




Fig. si i. — Uterine pack. 



~feo^,3i 




Fig. 512. — Vaginal pack with suprapubic pressure. 



after the removal of retained secundines from the uterine cavity, or 
in emergency cases, when profuse bleeding is associated with cancer, sar- 
coma, or fibroid tumor. Before introducing the tampon the oper- 
ator should know the exact size and length of the uterine cavity, and 
45 



706 



GYNECOLOGY 



the vagina and cervix should be carefully disinfected. A narrow pack is 
used, and the greater bulk of it is passed into the body of the uterus, a single 
strip usually being placed in the cervix, so that drainage from the body of 
the uterus will be perfectly free. Such a uterine tampon or pack may, be- 








Fig. 513. — Vaginal douche nozzle of glass. 






Fig. 514. — Sketch of correct position for douche. 



fore its introduction, be moistened with an antiseptic, such as the tincture of 
iodine, or with an astringent, such as a solution of suprarenal extract 
(Figs. 510 and 511). 

THE VAGINAL DOUCHE 

A vaginal douche may be used for three purposes: (1) Simply 
to cleanse the vagina ; (2) for the purpose of applying heat to the pelvis, so 



MECHANICAL AND MEDICINAL AIDS TO TREATMENT 707 

as to favor the absorption of intrapelvic inflammations and exudates ; (3) in 
order to bring an antiseptic, disinfecting, or astringent solution into contact 
with infected or inflamed cervical and vaginal surfaces. 

To be effectual, a vaginal douche should be taken with the patient in the 
recumbent posture (Fig. 517) ; if it is taken while in a sitting or semi- 
sitting position the douche water escapes almost as soon as it enters the 
vagina, and the solution may not reach all parts of the vaginal vault. The 
benefit derived from a douche used to promote absorption of pelvic exu- 
dates depends upon the degree of heat that is carried in this way to the 
bases of the broad ligaments and the pouch of Douglas, and the length of 
time it is maintained. In order to distend the vaginal vault as much as 
possible in such cases, the patient should lie in bed with the hips elevated 
upon a douche pan, but with no pillow under the shoulders. The douche 




Fig. 515- — Vaginal tampon, 

bag or reservoir should be suspended only a short distance above the level 
of the bed, so that the water will run very slowly. 

The water should be as hot as the patient can endure without discom- 
fort (110 R). A large quantity — a gallon and even two or three gallons of 
solution — is desirable, and at least from fifteen to twenty minutes should 
be consumed in giving the douche. The douche nozzle may be of glass or of 
hard rubber, with lateral perforations ; it should be carefully cleansed after 
using, and kept in a weak antiseptic solution (bichloride 1 : 4000). 

When the douche is used simply for its cleansing and thermic effect, it may 
be rendered bland by adding a tablespoonful of common table salt or borax 
to a gallon of water. When douches are used to allay inflammation or 
destroy infectious organisms in the vagina and upon the vaginal surface of 
the cervix, antiseptic and disinfecting agents are added to the water in 
various proportions, for example: Formalin, 1:1000; mercury bichloride, 
1:4000; lysol, 1 : 200 or 400, etc.; for deodorizing purposes, potassium per- 
manganate, 1 : 5000; for astringent purposes, powdered burnt alum or zinc 



708 



GYNECOLOGY 



sulphate, of each, I to 4 drams to a quart of water; or a douche powder 
that combines antiseptic and astringent properties may be prescribed, as, 
the ABC douche : Alum, y 2 ounce ; boric acid, 3 ounces ; phenol, y 2 ounce ; 




Fig. 516. — Filling vaginal tampon. (Anspach, in Hare & Landis' Modern Treatment. Lea & Febiger.) 

oil of gaultheria, 30 minims. Mix and use teaspoonful to quart of water 
as directed. 

THE VAGINAL TAMPON 

Vaginal tampons (Fig. 515) are used for the purpose: (1) Of 
applying hygroscopic, emollient, disinfecting, or astringent solutions to 



MECHANICAL AND MEDICINAL AIDS TO TREATMENT 709 

the vaginal walls or the vaginal portion of the cervix; (2) of exerting pres- 
sure upon the vaginal walls and giving a certain measure of temporary 
support to the uterus. They are made of absorbent cotton and lamb's wool 
— the latter being added for the reason that it does not " mat " when wet, 
helps to preserve the shape of the tampon, and is somewhat more resilient 
than cotton, and therefore capable of exerting more pressure. 

Tampons are made by placing over a strip of absorbent cotton a smaller 
strip of lamb's wool, and binding them together in the center. They 
may be made of any size. For hygroscopic purposes, as, e.g., to secure 
depletion of the uterus in cases of subinvolution, chronic pelvic inflamma- 




Fig. 517. — Good type of corset. 

tion, etc., glycerine is most commonly used ; epsom salts in finely powdered 
form is also effectual. For emollient purposes, as after the application of 
silver nitrate or the tincture of iodine to the vaginal surface, cold cream or 
zinc ointment is the most effectual ; when an antiseptic effect also is desired, 
phenol, 10 grains to 1 ounce, may be added to the zinc oxide, or a 10 per 
cent, ointment of ichthyol in petrolatum may be used. For antiseptic and 
disinfecting purposes aqueous solutions of argyrol and protargol (10 to 25 
per cent.) ; silver nitrate, 1 per cent. ; ichthyol, 10 to 20 per cent. ; dichloramine-T 
(2 per cent, in eucalyptol), etc., may be used. For astringent purposes dust- 
ing powders, such as equal parts of powdered burnt alum, boric acid, and 
bismuth subnitrate, or equal parts of tannic acid and lycopodium are 
most satisfactory. 



710 



GYNECOLOGY 




MECHANICAL AND MEDICINAL AIDS TO TREATMENT 711 



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712 GYNECOLOGY 

Tampons are either rilled with the solution (Fig. 519), ointment, or 
powder, as the case may be, and then introduced with a dressing forceps 
through a bivalve speculum, or the therapeutic agent is first introduced and 
the tampons inserted afterward. The patient should be told how many have 
been used, and she should be directed to remove them at the end of twenty- 
four hours. 

Tampons are used for the purpose of exciting pressure and giving sup- 
port in the gradual replacement of a retroverted uterus, previous to the 
fitting of a pessary. In such cases the tampons should be of small size, and 
the string to each one should be long enough to reach from the vaginal vault 
to a point well outside of the introitus. The tampons should be soaked in 
glycerine and packed into the vaginal vault with the patient in the knee- 
chest position (see page 704). 



CHAPTER XL 
RADIUM AND RONTGEN RAY THERAPY 

Radium. — Radium is a metallic element. It is used in the form of one 
of the salts (sulphate or bromide) ; the amount is always expressed in terms 
signifiying the amount of radium element in the salt. During some of its 
radio-active changes radium takes the form of a gas which is called the 
emanation. This emanation can be used for therapeutic purposes. 

Radium produces three varieties of radiations, designated as alpha, beta, 
and gamma radiations. The alpha rays have little penetrating power and 
no therapeutic value and may be confined by glass ; the beta rays are more 
penetrating and have therapeutic properties, but all except the most pene- 
trating are arrested by 2 mm. of lead; the gamma rays have the greatest 
penetrating power and are also used therapeutically. Although exposure to 
these rays has an injurious influence on all living cells, the normal tissues 
are more resistant than many of the tumor cells. On many tumor cells 
radium and the Rontgen ray have a selective action and the therapeutic use 
depends on this fact. 

1 In a general way. in the case of normal tissues, the more highly special- 
ized cells, especially glandular secreting cells as those of the skin, testicle, 
ovary, thyroid, and certain lymphoid structures as the thymus, are more 
susceptible to radium rays and the Rontgen rays. 

Cartilage, bone, fibrous connective tissue, and nervous tissue are very 
resistant. The effect of the rays on different tumor cells is very variable. 
Radium rays may disseminate a lymphosarcoma within forty-eight hours ; 
no visible change whatever may be noticed for five or six days after expo- 
sure of a carcinoma of the cervix to the same rays and yet the growth may 
disappear entirely in from five to six weeks. 

" From actual clinical experiences, taking account of the various physical factors in- 
volved: we feel that the ovary is at least ten times as easily injured as normal skin; 
that the vaginal wall is four or five times as tolerant ; that the mucous membrane and 
bladder wall are twice as tolerant ; that the lining of the uterus is about equally as tolerant 
as the skin ; that the rectal mucous membrane is equally tolerant ; that the cervix uteri 
is at least twenty times as tolerant. The figures are confessedly only rough estimates, but 
afford a good working basis for actual treatment. 

" The difference in toleration between the normal tissues and the epithelial new-growths 
in gynecologic cases is much more pronounced than in the dermatologic, which we have 
taken as our standard. The adenocarcinomata of the cervix uteri and of the body of the 
uterus are, on the average, more easily injured by radiation than are the epitheliomata 
of the same organs. It is our impression that most of the vaginal and cervical cancers 
are, as to tolerance, to be classified as more sensitive than the basal-celled epitheliomata 
of the skin. 

" Some rectal cancers of the adeno-type are four or five times as susceptible as the skin 
epithelioma, and all of them except the pearl-forming, squamous-cell cancer met with at 
the anal margin are decidedly more easily injured by radiation than the skin epitheliomata. 
The ordinary papilloma and the malignant papilloma of the bladder require about the 
same dosage as skin epithelioma of the basal-cell type. Uterine fibroid tissue is very 
much more susceptible to radiation than the normal skin — perhaps four or five times as 
easily influenced."' (Burnham.) 

713 



714 GYNECOLOGY 

Filters of various substances are used to lessen the local effect of the 
rays, e.g., lead, gold, platinum, silver, rubber, etc. The local reaction is also 
diminished by distance and increased by immediate contact. For example, 
packing the vaginal walls away from the cervix which is being exposed 
protects the vagina even better than a metal filter in contact with the 
vaginal wall. 

With an exposure sufficient to cause local necrosis at the point of con- 
tact, it has been proven that the destructive effect upon malignant cells 
is not exerted beyond a distance of 2 to 4 cm. The gamma rays of radium 
are practically identical with the Rontgen rays. The therapeutic action of 
each is practically the same, but in many gynecological cases radium can be 
used with advantage in place of the Rontgen ray, since it can be applied 
more directly. 

Histologically, the general changes noted in a malignant growth after 
radiations are disintegration of the tumor cells and formation of new con- 
nective tissue poor in blood-vessels. 

CARCINOMA OF THE CERVIX 

Radium is the most valuable therapeutic agent at our command in the 
treatment of advanced carcinoma of the cervix. Experience has shown that 
recurrences following operation or radium treatment are not as amenable as 
primary growths. In the early and distinctly operable stage, radium treat- 
ment cannot yet be regarded as the procedure of choice. 

The best treatment for early and distinctly operable cases at the present 
time seems to be operation immediately following radium treatment of the 
carcinomatous area. This immediate preparatory treatment with radium is 
supposed to affect some of the cancerous cells beyond the operative area, 
and possibly also to prevent lymphatic dissemination. 

In borderline cases, that is. those in which the disease has evidently 
passed through the cervix on one side, but in which the uterus retains 
enough mobility to encourage the operator to remove it, radium alone should 
be used. 

Operation some time after radium treatment, the treatment having been 
given for the purpose of rendering inoperable or borderline cases operable, 
and which has been advised and practised, is not to be encouraged. Radia- 
tion renders the operation technically difficult, and the operation subjects 
the patient to the risk of disseminating quiescent and walled-off 
cancerous cells. 

Radium treatment is the most effective treatment for recurrences after 
operation, but after all, it is not very succesful. Nevertheless, in even the 
most hopeless cases, it may be of the utmost benefit short of a complete cure. 
Radiation is the treatment par excellence in cases of cancer of the cervix that 
are advanced and inoperable at the time they come under observation, but 
there are cases in which the disease is so far advanced locally that destruc- 
tion of the carcinomatous growth will produce rectal or vesical fistula with- 
out any hope of permanent benefit. Curiously enough, even in some cases which 
present distinct metastases at a distance, radium treatment may be considered 
justifiable for the purpose of relieving disagreeable local manifestation. 



RADIUM AND RONTGEN RAY THERAPY 715 

In carcinoma of the cervix, radium treatment is supplied by the introduc- 
tion of the radium salt or of the radium emanation directly into the cancerous 
area. In no case should radium treatment be preceded by curettement. No 
disturbance of the carcinomatous mass is permissible further than the use 
of a cautery knife, and this only when it is necessary to make room for the 
radium tube or to secure tissue for histologic diagnosis. When needles are avail- 
able, they may be plunged directly into the mass. The radium salt or ema- 
nation should be introduced into the center of the carcinomatous tissue. 
The dose should be at least 2000 mg. hours. It is not practicable to use less 
than 50 mg. of radium in the treatment of cancer of the cervix. 

The usual dose, as, for example, that used by Clark, is 100 mg. of radium 
screened with platinum and rubber, with an exposure of twenty-four hours. 
The rectum and bladder are protected by malleable lead plates, or by 
gauze packing which holds the vesicovaginal and the rectovaginal wall at 
some distance. Kelly and Burnham use a larger amount of radium element 
for shorter periods of time, as, for example, as much as 500 mg. for eight 
hours, to 3000 mg. for one hour. Miller uses 75 to 85 mg. of radium intermit- 
tently, giving from 3000 to 5000 milligram hours within a week or ten days. 

When radium is used, the vesicovaginal and rectovaginal septa must be 
protected by suitable screens of lead or gold. These tissues may be pro- 
tected also by the interposition of gauze packing which separates them from 
the radium. Distance is a good protector, the effect of radium on tissues 
being inversely as the square of the distance. If the vesicovaginal and recto- 
vaginal walls are not sufficiently protected, cystitis, proctitis, ulceration, 
fistula formation, and infection may ensue. 

More than half of the cases are benefited : hemorrhage, discharge, and 
pain disappear ; the appetite improves, the color returns, and the patient 
gains in weight. In most cases this improvement lasts for at least six 
months, when the pain, emaciation, etc., reappear. Although nothing may 
be noted at the immediate original site of the cancer, upon making bimanual 
examination extensions from it may be discovered in the broad and utero- 
sacral ligaments and in the rectovaginal and the vesicovaginal septa (Clark). 

In some cases the general and local indications of the disease disappear 
for a longer period. In those extending over a period of five years, the 
result may be considered a cure. Kelly and Burnham report one case alive 
after seven years and six after six years. 

The use of radium is too recent to warrant an estimate as to the durability 
of its effects. 

Of Kelly and Burnham's series of 327 cases one is alive after seven years, 
six after six years, three after three years, 19 after two years, 22 after one 
year, etc. 

Clark reports a total of 209 cases. Seventy-three are living: one after 
five years, four after four years ; 1 1 after three years ; 23 after two years, and 
34 after one year. Twenty-five could not be traced ; 1 1 1 are dead. 

Recasens, in a series of 200 cases treated with radium and the Rontgen 
ray, claims to have secured 70 per cent, of relief for the inoperable cases, 



716 



GYNECOLOGY 



and ioo per cent, relief for the operable cases. He speaks of the condition as 
a " clinical cure,'' but only 2*j of his cases at the time of his report (1917) were 
of more than two years' duration and but 45 were more than one year old. 

Kelly and Burnham, Recasens, and others advise a combination of 
radium and the Rontgen ray, the applications being made externally, 
through the abdomen or through the sacrum by cross-firing through several 
ports of entry. Case calls attention to the fact that the Rontgen ray is a 



I 




Fig. 526. — Means of applying radium in gynecological diseases; to the left, needles contain- 
ing radium which may be thrust into malignant tumors; to the right, radium enclosed in 
platinum capsules and encased in rubber tubing, ready for intrauterine application. 



much more powerful agent than radium in proportion to the time consumed. 
Radium is to be used in the uterus where it can be applied more directly 
to the cancerous area, whereas the Rontgen ray, directed from the outside, 
affects the deeper tissues and lymphatics that have escaped the influence of 
the radium. 

A repetition of the radium application may be undertaken within a period 
of from four to eight weeks. 



RADIUM AND RONTGEN RAY THERAPY 717 

The Rontgen ray applications are made in series of seances conducted 
about three to four weeks apart. 

CARCINOMA OF THE FUNDUS 

The results of operation, except in advanced cases, are so good that 
dependence upon radiation is not often justified. It should be used only as 
a palliative measure in advanced inoperable cases or when there is some 
grave counter-indication to hysterectomy. 

MYOMATA UTERI 

The application of either radium or the Rontgen ray will control 
the hemorrhage of myomata uteri, the growths in most cases being 
gradually reduced in size and some finally becoming unrecognizable. In 
view of this fact and others, it might at first sight appear that radiation 
was the procedure of choice in the treatment of myoma uteri. This is not 
the case, for, while radiation is to be preferred for certain myomata, the 
majority of cases require operation. 

The following are the disadvantages of radiation : 

1. Although radiation arrests hemorrhage and tends to reduce the tumor, 
a nucleus of the latter may remain which later will give trouble. 

2. Malignant complications may be overlooked either in the tumor itself 
(sarcoma) or in the endometrium (carcinoma). Myomata are sarcomatous 
in 2 per cent, of all cases ; in 9 per cent, of submucous tumors. Although a 
diagnostic curettage can effectually rule out malignant degeneration in the 
endometrium, in many cases of myoma uteri there is such distortion of the 
uterine cavity that it is imposible to reach all parts of the endometrium 
with a curette. Frank insists that radiation is not permissible unless a thor- 
ough diagnostic curettage is possible. 

3. Certain intrapelvic complicating lesions, such as adherent and closed 
adnexa, ovarian cysts, etc., may be overlooked ; in a small proportion of 
cases these give trouble after radiation, and while they do not threaten life, 
a certain amount of morbidity must be entailed. Stein quotes many cases 
in which the Rontgen ray failed to reduce the tumor, and upon operation sarcoma, 
at times inoperable, was discovered. Tracy, in a collection of 3561 cases of 
myomata, estimated that 33 per cent, could not have been cured by the 
Rontgen ray because of malignant degeneration and adnexal lesions. 

4. In young women radiation may destroy or seriously impair the re- 
productive functions. While the condition of the patient may be such as to 
make this a secondary consideration, in most instances it is a most impor- 
tant matter. When the myomata are single or pedunculated, myomectomy 
removes the growth without mutilation of the pelvic organs or impairment 
of their function. 

5. While the effect of radiation on hemorrhage in myomata is in any case suf- 
ficiently prompt, when the growths are producing serious pressure symptoms, 
as, e.g., vesical and ureteral obstruction, with cystitis and pyelitis, etc., it 
may be inadvisable to wait for the shrinkage of the radiated growths, as 
this may cover a period of months or even years. 



718 GYNECOLOGY 

6. When myomata are complicated by inflammatory adnexal lesions or 
ovarian tumors, radiation is inadvisable for two reasons : First, because 
radiation sometimes renders them worse, and secondly, because it never 
effects a cure. 

J. When myomata are necrotic, radiation tends to aggravate the condi- 
tion by predisposing to infection and diminishing the blood supply. 

The advantages of radiation are as follows: 

i. There is practically no operative mortality: in Rontgen ray cases 
there is no anaesthesia risk; there are no post-operative complications. The 
patient is ambulant, and there are fewer hospital days. While in a selected 
series of cases the risk of operation has been as low as or lower than i per 
cent., Kelly draws attention to the higher death-rate in general following 
operations for myomata, and also to the morbidity that follows operations. 
He thinks, therefore, that radiation by radium is the procedure of choice. 

2. Radiation for the control of hemorrhage can be used with success and 
without hesitation in any patient, no matter how serious her condition. 

3. If radiation fails, operation may later be undertaken without detri- 
ment to the patient. Pfahler observes that in 1915 from 2000 to 3000 fibroid 
cases had been treated by the Rontgen ray. If, later on, malignant degen- 
eration were common, many cases would by this time have been reported in 
the literature. Furthermore, since radiation is successful in curing some in- 
operable carcinomata, why may it not be curative of unsuspected 
malignant growths? 

4. The menopausal symptoms after cure by radium treatment are not so 
marked as after operation with complete ablation of the ovaries. 

The consensus of opinion to-day among gynecologists in this country is 
that, in a majority of cases operation is to be preferred to radiation, and that 
the latter should be reserved for those in whom the advantages to be gained 
by operation are overbalanced by the dangers incident to the patient's condition. 

Radiation is admittedly not suitable for complicated cases {e.g., degenera- 
tions of tumor, endometrial disease, adnexal lesions), and it is in these cases 
that the operative mortality is highest. In the uncomplicated cases the 
operative mortality is exceedingly low (less than 1 per cent.) ; the patient is 
permanently cured, and there is no danger of a subsequent growth or of 
degeneration of the shrivelled remains. 

Radiation is, therefore, reserved for : 

1. Myomata in which the preponderating symptom is hemorrhage ; espe- 
cially in intramural tumors, when the uterus is smaller in size than a four 
months' pregnancy (Clark), and all parts of the endometrium may be 
reached in a diagnostic curettage. 

2. Myomata complicated by anaemia, organic heart disease, diabetes, 
chronic nephritis, serious pulmonary disorders, goitre with heart symp- 
toms, and other general lesions that increase the risk of operation. 

Radiation is contraindicated : 

1. When myomectomy is possible without impairing the reproductive 
functions. 

2. When the dominating symptoms are due to pressure and the uterus is 
larger than a four months' pregnancy ; especially in multiple tumors of the 



RADIUM AND RONTGEN RAY THERAPY 719 

submucous and the subserous type, as well as in a degenerating tumor or 
tumors complicated by adnexal lesions, or in cases in which these factors cannot 
be excluded. 

Radium is the form of radiation that is particularly useful, since it can be 
introduced directly into any part of the uterovaginal canal. Radium should, 
therefore, be used as a rule, but in extremely large growths the Rontgen ray 
may be used with advantage to supplement the action of the radium ; when 
the latter is not available, the Rontgen ray is an almost equally efficient 
alternative, although not so convenient or so rapid in its effect. 

The results of radium treatment have been gratifying. Kelly and 
Burnham state that, in their opinion, with increasing experience 90 per cent, 
of myomata may be dissipated by radium without serious discomfort or 
risk. They report 210 cases in which the age ranged between 26 and 67. 
In some the tumor reached almost to the umbilicus. In nearly every case 
shrinkage or disappearance followed in from two to 18 months. Clark and 
Keene, Miller, and others report similar results. 

The technic of application varies. Kelly and Burnham believe in giving 
large doses over a short period of time. They use, as a rule, a single intra- 
uterine dose of 1500 millicurie hours. Extremely large tumors are also at- 
tacked by supplementary massive treatment through the abdominal wall. 

Clark and Keene, and Miller use 50 mg. of radium, screened by a platinum 
capsule and a rubber sheath, for 24 hours. This is a most success- 
ful and rational plan of treatment. A preliminary curettage is performed 
under local, nitrous oxide and oxygen, or ether anaesthesia. The depth of the 
uterine cavity is then measured, and the radium capsules, in either single, 
double, or tandem formation, are inserted to the fundus. Care must be 
taken not to allow the radium to remain in contact with the cervical canal. 
Nausea and sometimes lower abdominal pain and tenderness follow, as a 
rule, but in a majority of cases subside rapidly after removal of the radium. 
In some cases these symptoms may persist for a few days. 

Radium produces its effect by causing an obliterative endoarteritis 
affecting the endometrial vessels ; there may also be an influence 
upon the ovaries (destruction or inhibition of follicular development), but 
this is somewhat doubtful from an intrauterine application. To affect the 
ovaries Boggs applies 25 mg. of radium to the vaginal vault on each side of 
the cervix. 

Following the use of radium, bleeding is checked and may not return ; 
sometimes there is increased hemorrhage for a time, or the bleeding may be 
irregular. If the first application does not produce the desired result, a 
second application may be made after a period of several months. Follow- 
ing the use of radium, a slight irritating leucorrhcea may occur for a time. 

The Rontgen ray may be used as supplementary to radium or, when 
radium is not available, it may be used alone. 

Deep therapy, cross-firing, and filtration are necessary. Definitely local- 
ized single myomata may be treated directly, the ovaries being screened 
for protection. 

There is no danger to the skin when the correct technic is carried out 



720 GYNECOLOGY 

and there is no visceral disturbance. Constitutional symptoms, such as lassi- 
tude, etc., are due to the absorption of gases that collect about high- 
tension currents. 

Lange, who believes that malaise, nausea, anorexia, glandular enlarge- 
ments, and metallic taste are due to acidosis, prescribes 30 grains of sodium 
bicarbonate every three or four hours. The proper ventilation of the treat- 
ment room is of the utmost importance (Pancoast). 

HEMORRHAGIC UTERI 

Almost every form of benign uterine hemorrhage is favorably influ- 
enced by radium treatment. Under this heading may be grouped hemor- 
rhages due: (1) To myopathic changes; (2) to glandular hyperplasia of 
the endometrium ; (3) to functional disturbances of the ovary or ductless 
glands ; (4) to general diseases, such as heart, kidney, and liver disorders, 
circulatory lesions, etc. 

These hemorrhages may either threaten life, by producing anaemia, or 
they may merely be a constant source of annoyance. 

Radium is more satisfactory than the Rontgen ray for the reason that it 
can be applied in conjunction with a diagnostic curettage and because its 
effect is produced locally upon the capillaries of the endometrium, whereas 
the Rontgen ray must first influence the ovary and secondarily the circula- 
tion of the uterus. One radium treatment is usually sufficient. 

Kelly and Burnham, Clark and Keene, and Miller, have used radium ■) 
with success in these cases, and together report upward of 72 cases. 
There are two plans of applying the radium. Kelly and Burnham ' 
use a tiny capsule of radium emanation (500 to 1000 mc.) which is fastened 
to the end of a uterine sound. The emanation bulb is then placed in con- 
tact with successive areas of the uterine interior for a certain number of 
minutes at a time. The patient is maintained in position by means of pil- • 
lows placed under the knees and by sand-bags placed on each side. The 
sound is kept in position by strapping it to sand-bags placed between the ' 
patient's knees. When a 500 mc. application is used there should be eight 
areas, and the application to each one should last fifteen minutes. When 1 
these observers consider complete and rapid cessation urgent, in addition | 
to the internal radiation they make external applications, 1 gm. of radium 1 
being placed on either side of the lower abdomen over the true pelvis, 3 inches ' 
from the skin, and allowed to remain for from four to six hours. 

External Rontgen ray treatment also may be used in conjunction with 
internal radium treatment. 

Clark and Keene, and Miller apply the radium element or salt to the 
uterine cavity, screened with a platinum capsule and a rubber tube. The 
radium capsules are placed in single, double, or tandem formation, depend- 
ing on the strength of the capsules, the dose, and the length of the endo- 
metrial cavity beyond the internal os. 

When the hemorrhage is serious and the patient is over forty, and it is 
immaterial whether or not the menopause is induced, 50 mg. are used with 
twenty-four hours' exposure. In young women, when the symptoms are 



RADIUM AND RONTGEN RAY THERAPY 721 

less urgent and it is undesirable to produce a permanent amenorrhoea or a 
premature menopause, a dose of from 25 to 50 mg. is used, and the exposure 
lasts from three to eight hours. 

Radium treatment should, in all cases, be preceded by a diagnostic curet- 
tage, otherwise it is not permissible. In the presence of adnexal lesions 
radium treatment is contraindicated, for it often aggravates them. 

Cessation of the bleeding is usually prompt, but occasionally there are 
one or two free periods following the treatment ; this, too, even if complete 
cessation of the periods has been desired and is subsequently accomplished. 

It has been stated that radium treatment with a larger dose and for a 
shorter period is followed by less abdominal tenderness, also a diminution 
in the watery leucorrhcea that is almost always observed for a time. 

When complete and permanent amenorrhoea takes place, only one-third 
of the patients complain greatly of menopausal symptoms ; one-third experi- 
ence very slight discomfort, and one-third complain of no discomfort whatever. 

CARCINOMA OF THE VULVA 

There is some reason to doubt the efficacy of radium in the treatment of vul- 
var growths. In one case in which a carcinomatous area in the labium majus was 
excised, with implantation in the wound of 50 mg. of radium for eight hours, a 
carcinomatous superficial inguinal gland was removed, and an enlargement of the 
deep inguinal glands was exposed to the Rontgen ray, improvement oc- 
curred and there was no recurrence after eight months. Another ex- 
tensive (3 by 5 cm.) carcinoma of the labium majus, treated by radium 
alone, grew rapidly worse. The only patient in Janeway's series did badly, 
in spite of the fact that the lesion did not seem far advanced (1^2 inches in 
diameter). Duane and Greenough treated three cases of vulvar carcinoma 
without securing any improvement. 

No doubt in malignant tumors of the vulva operation is the procedure 
of choice, applications of radium being made later to prevent recurrence. 
Nevertheless, in late inoperable cases, radium is the only recourse, and should 
always be tried. Sarcoma of the vulva, especially of the melanotic type, 
rodent ulcer, and lupus vulvae may be favorably influenced. Pruritus 
vulvae is rapidly and favorably influenced by radium in many instances (50 
per cent, cured, 25 per cent, improved, 25 per cent, unimproved) (Pancoast). 
The Rontgen ray is also useful here, as reported by Steiger, who treated 
pruritus ani by the same method. 

PAPILLOMATA AND CARCINOMATA OF THE BLADDER 

Geraghty has employed radium for the past two years in bladder papillomata 
that have shown histologic changes characteristic of malignant papillomata, or 
those in which the growths were unusually resistant to fulguration. There have 
been eighteen cases, seven of them multiple. Two patients discontinued treat- 
ment, but in the remaining sixteen the tumors were completely destroyed. 
In all but one cystoscopic examinations had been made subsequently, and 
four recurrences were noted. Six other cases of the malignant papilloma 
46 



722 GYNECOLOGY 

type that had responded only slightly to fulguration, after varying amounts 
of radium, yielded readily to the high-frequency current. 

In twenty-four cases of papillary carcinoma Geraghty concluded that 
radium was of no use, either alone or in combination with fulguration. 

Barringer used radium in twenty-five cases of carcinoma of the bladder, 
of whom twenty-three were impossible operative risks. In four (three con- 
firmed as cancer by microscopic examination) radium removed the growth 
locally (ten and one-half months, five months, and less), and one 
showed slight symptoms of local recurrence, the microscopic examination, 
however, being negative. Of the twenty-one remaining cases, eight had 
died at the time of his report (1918) ; two were improving, one was hopeless, 
one had shown some indication of having been benefited ; four had not 
been heard from, and the remainder were too recent (1917) to be conclusive. 

Geraghty employed about 103.7 mg. of radium in a brass capsule (some- 
times the /3-rays were filtered with platinum). The capsule was introduced 
in the beak of an instrument through which an observation cystoscope could 
be passed. After accurate placing of the radium, the instrument was held in 
a fixed position by means of a mechanical arm attached to the cystoscope 
table. The radiations were given for an hour at a time, and the seances 
were repeated from one to three times weekly, depending upon the tumor 
and the reaction of the patient. 

Barringer's plan was to introduce the radium tubes (emanation screened 
with silver and rubber, 50 to 100 mc.) into the bladder through a cystoscope. 
As most tumors are situated in the trigone, the patient was placed in the 
recumbent posture and the radium was kept in close contact with the 
growth. If the growths were in the vault or upon one of the lateral walls, 
the patient was placed upon the abdomen or upon one or the other side. 

Hirst and Pancoast have one patient who had an extensive papillary car- 
cinoma involving the base of the bladder upon whom they did a suprapubic 
cystotomy, and then with free exposure of the growth, used desiccation fol- 
lowed by radium treatment. She remains without symptoms and free, so 
far as they are able to determine of a recurrence of the tumor after 
three months. 

In women suprapubic cystotomy and free exposure are advisable, as a rule, 
preliminary to fulguration and radium treatment. 

RECTAL DISEASES 

Both adenocarcinoma of the rectal mucosa above the sphincter 
region and squamous epithelioma of the anus have shown some sus- 
ceptibility to radium treatment. Adenocarcinoma is definitely curable 
in rare instances and favorably influenced in a few cases. Radiation may 
be tried in early cases, when operation w r ould mean serious mutilation. If 
radiation fails, operation can still be resorted to. The difficulty in the use 
of radium in the treatment of cancer of the rectum lies in the technic of its 
application ; this difficulty is increased by the fact that the function of the 
bowel is of necessity more or less continuous. A satisfactory plan is to 
expose the entire tumor-bearing area through a speculum. A piece of 



RADIUM AND RONTGEN RAY THERAPY 723 

muslin containing the radium tubes is then introduced and spread over the 
tumor. Over this sufficient gauze packing may be placed to push away and 
protect the opposite rectal wall. A more exact method consists in making 
a cast of the cavity of the rectum out of dental composition and embedding 
the radium tubes on its surface in contact with the lesion ; or a disk contain- 
ing the radium may be attached to the proctoscope and applied, under direct 
observation, to the tumor. 

In advanced annular carcinomata of the rectum, after performing colos- 
tomy, a string may be washed through the rectum out of the anus, and by 
this means radium tubes may be drawn through into successive positions 
in order to expose every part of the affected bowel. 

The technic of application in epithelioma of the anus is simple. These 
tumors are more malignant and less amenable to the treatment than adeno- 
carcinoma. Metastases from the anus to the inguinal lymphatic glands is a 
factor that exerts an unfavorable influence on the prospects of cure. Janeway 
reported thirty-four cases of cancer of the rectum treated with radium. Two 
had completely retrogressed and showed no evidence of disease at the time 
his report was made (1917) ; fourteen had been improved, whereas eighteen 
were classed as unimproved. 

ABDOMINAL TUMORS 

Burnham and Kelly report that immense growths of this type 
have completely disappeared under radium treatment. Favorable results 
also were observed in colloid carcinoma of the intestine, cancer of 
the liver and stomach, ascites from abdominal cancer, hypertrophy of the 
spleen, and sarcoma of the kidney. 

One case of bilateral papillocarcinoma of the ovary with diffuse peri- 
toneal metastases has been observed in which, after removal of the 
pelvic tumors and recurrence of tumor formation and ascites in the abdo- 
men, the Rontgen ray caused a recrudescence of the abdominal masses and 
disappearance of the ascites for a period of two years. The ascites then 
reappeared and in spite of repeated tappings and Rontgen ray treatment the 
patient died within a year. 

In the treatment of such conditions with radium immense quantities are 
required, so that the treatment is available in few localities. Rontgen ray 
treatment is more generally applicable in these cases. 

BIBLIOGRAPHY 

Abbe, R. : "Uterine Fibroids, Menorrhagia, and Radium." Med. Record, 191 5, lxxxvii, 379. 

Bailey, H. : " Radium in Uterine Cancer." Trans. Amer. Gyn. Soc, 1917, xlii, 438. 

Brettauer, J. : " Final Results of Rontgen Ray Treatment of Fibroids of the Uterus." Trans. 
Amer. Gyn. Soc., 1918, 364. 

Burnham, C. F. : "A Brief Outline of the Status of Radium Therapeutics." Bull. J. H. H., 
1915, xxvi, 190. 

Case, J. T. : " The Rontgen Treatment of Uterine Carcinoma." S., G. and O., 1916, xxii, 
No. 4, 429; Ibid. : " The Present Status of Rontgentherapy in the Management of Deep- 
seated Malignancy." S., G. and O., 1917, xxiv, No. 5, 580; Ibid.: "Rontgen Therapy." 
P. M., 1918, 171. 

Clark, J. G. : " The Therapeutic Use of Radium in Gynecology." S., G. and O., June, 1918. 

Clark, J. G., and Keene, F. E. : " The Use of Radium in Cases of Benign Uterine Hemor- 
rhage." Trans. Amer. Gyn. Soc, 1917, xlii, 424. 



724 GYNECOLOGY 

Cole, C. G. : " Technic and Experimental Application of Hard Rays for Deep Rontgen 
Therapy." Trans. Amer. Gyn. Soc, 191 5, xl, 215. 

Duane and Greexough : " Report of Results of Radium Treatment at the Collis P. Hunt- 
ington Memorial Hospital by the Cancer Commission of Harvard University." Boston 
Med. and Surg. Jour., 1917, clxxvii, 359. 

Frank, R. T. : " X-Ray Treatment of Uterine Hemorrhage." Trans. Amer. Gyn. Soc, 

1916, xl, 460; Ibid. : S., G. and O., 1916, xxiii, 243. 

Heynemann, Th. : " Gynakologische Strahlentherapie." Therap. Monatschrift, 1915, 
xxix, 78. 

Janeway, Barringer and Failla : Radium Therapy in Cancer. Hoeber, New York, 1917. 

Kelly, H. A. : " Radium Therapy in Cancer of the Uterus." Trans. Amer. Gyn. Soc, 1916, 
No. 41, 532; Ibid.: "Methods and Results of Radium Treatment of Uterine Hemor- 
rhage Due to Other Causes Than Malignancy." Trans. Amer. Gyn. Soc, 1917, xlii, 408; 
Ibid. : "The Radium Treatment of Fibroid Tumors." S., G. and O., 1915, xx, 271. 

Kelly, H. A., and Burnham, C. F. : " Radium in the Treatment of Uterine Hemorrhage 
and Fibroid Tumors." Trans. Sect., O., G. and A. S., A. M. A., 1914, 237; Ibid.: 
" Radium in the Treatment of Carcinomas of the Cervix Uteri and Vagina." J. A. M. A., 

1917, lxv, 1874; Ibid. : "Two Hundred and Ten Fibroid Tumors Treated by Radium." 
Trans. Amer. Gyn. Soc, 1918, 317. 

Lange, S. : " The Cause and Prevention of the Constitutional Symptoms Following Deep 
Rontgentherapy." Amer. Jour Rontgenology, 1916, iii, 356. 

Miller, C. J. : " Radium in the Treatment of Carcinoma of the Cervix Uteri." S., G. and O., 
1916, xxii, No. 4, 437; Ibid.: "Radium in the Treatment of Certain Types of Uterine 
Hemorrhage and Uterine Fibroids." Trans. Amer. Gyn. Soc, 1917, xlii, 2>77- 

Pfahler : " Rontgenotherapy in Uterine Hemorrhage." Trans. Sect., O., G. and A. S., 
A. M. A., 1914, 251 ; Ibid. : Rontgen Therapy in Uterine Fibroids and Uterine Hemor- 
rhage." Trans. Amer. Gyn. Soc, 1915, xl, 199. 

Pfahler, G. E. : " Rontgenotherapy in Uterine Fibroids and Uterine Hemorrhage." Amer. 
Jour. Obst, 1915, lxxii, 79. 

Pfahler and McGlinn : Rontgenotherapy Successful in Uterine Fibroid Without Affect- 
ing the Ovaries." Amer. Jour. Obst., 1917, lxxvi, 262. 

Prime : " Radium and Cancer Experimental Work." Prog. Med., 1918, 163. 

Recasens, S. : " La Radiumtherapie dans le cancer de l'uterus." Arch. mens, d'obst. et 
de gyn., 1917, 34- 

Schmitz, H. : " An Additional Contribution to the Therapeutic Value of Radium in Pelvic 
Cancers." S., G. and O., 1916, xxiii, No. 2, 191. 

Steiger, M. : " Bisherige Erfahrungen und Resultate aus dem Rontgeninstitut der Univer- 
sitatsfrauenklinik." Bern. Cor.-Bl. f. Schweiz. Aerzte, 1915, February 27, xlv, 257. 

Stein, A. : " The X-Ray Treatment of Uterine Myomata — A Warning Based on a Study 
of the Literature." Med. Record, Wm. Wood & Co., New York, 1916, lxxxix, 991. 

Shoemaker, G. E. : " Sarcomatous Degeneration of a Uterine Fibroma Five Years After 
Rontgen Ray Treatment for Pressure and Hemorrhage." Jour. Amer. Med. Assoc, 
1915, lxiv, 1653. 

Tracy, S. E.. "A Report of 100 Consecutive Cases of Fibromyomata Subjected to Opera- 
tion." Trans. Sec, O., G. and A. S., A. M. A., 1916, 299. 



CHAPTER XLI 
VACCINE AND SERUM THERAPY IN GYNECOLOGY 

Specific therapy — by vaccines and sera — in the treatment of gonococcus 
infections of the female pelvic organs has not achieved the marked curative 
results seen in other diseases. However, in many instances marked im- 
provement of the lesion and amelioration of the symptoms has followed the 
use of specific measures either alone or used to supplement appropriate 
local treatment. 

Injection of specific serum has not been in frequent use, due to the diffi- 
culty in most cases of establishing the exact identity of the causative organ- 
ism. Sera for gonococcus infections are usually prepared by immunizing 
rabbits and sheep. They should not be used during the acute period of the 
disease, the so-called negative phase of the infection, but better later when 
the patient is not so overwhelmed with toxins, yet still has a moderately 
active infection. The serum confers a passive immunity rather than an 
active one. The dosage may vary from 20 to 100 c.c. given every twenty-four 
hours or more. In general it may be said that the serum is more efficacious 
in such complications as arthritis, endocarditis, and general septic conditions 
associated with gonococcus infections of the genito-urinary tract than in the 
treatment of the simple forms of gonococcal urethritis, vulvitis and cervicitis. 

Auto Serum Therapy. — In the treatment of gonorrhceal arthritis good 
results have followed the injection of 5 to 10 c.c. of the patient's own serum. 

Vaccine therapy of gonococcus infections of the female pelvic organs has 
shown different results in the hands of various observers. Vaccines may 
be autogenous, polyvalent, or mixed, i.e., with other organisms. The gono- 
coccus is hard to cultivate. It grows best in original culture on haemoglobin 
or hydrocele fluid agar. After once establishing the growth the gonococcus 
will grow readily upon most media. Naturally an autogenous vaccine is to 
be preferred. But lacking this, and due to the variances in the different 
strains of the organism, it is advisable to use a polyvalent or stock vaccine. 
In some instances a mixed vaccine is of value, when to the polyvalent 
gonococcus vaccine is added various combinations of vaccines, such as colon 
bacillus, micrococcus catarrhalis, staphylococci and diphtheroid bacilli. 
Whatever the nature of the vaccine it should always be used as a comple- 
ment to the necessary and appropriate local therapeutic measures. 

Vaccines have been used extensively in the vulvovaginitis of children. 
The poor results from vaccines in the hands of some observers may be due, 
as Louise Pearce has shown, to the fact that the organism found on the 
vulva of infants differs immunologically from the organism found in adult 
urethritis. Here, preferably, an autogenous vaccine should be used. In the 
treatment of leucorrhcea, vaginitis, and cervicitis, Curtis found that vaccine 
therapy gave very satisfactory results for a time. A considerable number 
showed decrease in the discharge while under treatment without attainment 

725 



726 GYNECOLOGY 

of a point of absolute cure. Many had a slight return of discharge on 
cessation of treatment. Most important in his investigation was the cure or 
relief of such associated symptoms as malaise and backache when an autog- 
enous vaccine was used. Vaccines have not been used in sufficient degree in 
salpingitis, oophoritis, or metritis to warrant conclusions being drawn as to 
their therapeutic value. In the treatment of arthritis, which frequently 
complicates gonococcus infection of the genito-urinary tract, vaccines have 
proved to be valuable adjuncts. 

The dosage should be from 50 to 100 million every three to five or six 
days, and may be increased to as high as 500 millions. Reactions should be 
looked for, and may occur as local, focal, or general. In case of a severe 
reaction of any nature the dose should be cut in half for the next injection 
and treatment continued cautiously. The local reaction has been made use 
of at times as a diagnostic means. A few drops of a gonococcus vaccine are 
injected intracutaneously after the manner of producing the well-known 
tuberculin reaction. A positive reaction is manifested by the appearance in 
from twenty-four to thirty-six hours of a small papule at the point of injec- 
tion, surrounded by an areola of erythema. This disappears in a few days. 
A negative reaction is a slightly yellowish discoloration at the point of injec- 
tion. A diagnostic focal reaction following a subcutaneous injection might 
be expressed by lessened tenderness and softening of the mass, as in a 
pelvic lesion. 

In general, it may be said that vaccines and sera are often valuable aids 
to treatment and merit extended use in many cases (see also Treatment of 
Puerperal Pelvic Inflammatory Disease, p. 424). 

BIBLIOGRAPHY. 

Curtis, A. H. : " On the Pathology and Treatment of Chronic Leucorrhea." Surg., Gyn. 

and Obst., 1914, vol. xix, 25. 
Hamilton, B. W. : "Gonococcus Vulvovaginitis in Children." Jour. Am. Med. Assn., 

1910, liv, 1 196. 
Hensius, F. : " Versuche zur Vaccine Behandlung der weiblichen Gonnorrhoe." Monatschr. 

f. Geburtsch. u. Gynak., 191 1, xxxiii, 426. 
Morrow, L., and Bridgmax, O. : " Gonnorhcea in Girls, Treatment of Three Hundred 

Cases." Jour. Am. Med. Assn., 1912, lviii, 1564. 
Neu: " Vakzinetherapie." Monatschr. f. Geburtsh. u. Gynak., 1913, xxxviii, 182. 
Sternberg, A. J. : " Zur Vakzindiagnostik der Gonorrhoe des Weibes." Gyn. Rundschau. 

1912, vi, 701. 
Taussig, F. J. : " The Prevention and Treatment of Vulvovaginitis in Children." Am. 

Jour. Med. Sci., 1914, cxl. 
Weinstein, E. : " Die Vakzinetherapie nach Wright bei der Vulvovaginitis der Kinder." 

Miinchen. med. Wochnschr., 1910, lvii, 762. 






INDEX 



Abderhalden serum test in pelvic disease, 107 
Abdomen, examination of, 131, 520 
exploration of, 639 
mensuration of, 137 
pendulous fat, 550 

treatment of, 551 
regions of, 116 
Abdominal, bandages, 696 
binder, 696 
examination, 131, 520 

by auscultation, 137 

by palpation, 131, 132 

by percussion, 134 
hysterectomy, 317 
incisions, 624 

Battle's, 505, 625, 626 

closing, with drainage, 646 

directions regarding, 633 

dressing, 646 

gridiron, 627 

high paramedian, 625 

lateral, 625 

local anaesthesia in, 652 

low paramedian, 624 
operations, preparations for, 621 
organs, remote from pelvis, 137 
ptosis, 508, 550 
support, 551, 696 
tumors, radium in, 723 
viscera, diseases of, 500 

associated with pelvic disorders, 
500 

exploratory laparotomy for, 639 

related to pelvic disorders, 500 
wall, 60 

examination of, 520 

relaxation of, 550 
treatment of, 551 
Abortion, 80, 95 

in relation to pelvic disease, 95 
tubal, 371 
Abscess, of appendix, 500 
of Bartholin's gland, 186 
of incision, post-operative, 689 
of kidney pelvis, 471 (see also Pyelo- 
nephritis) 
of ovary, 381 
of pelvis, 428, 690 
of uterus, intramural, 282 
suburethral, 445 
_ tubo-ovarian, 365 
Acidosis, in operative cases, 619 
post-operative, 693 

diagnosis of, 692 

etiology of, 692 

symptoms of, 692 

treatment of, 693 



Acute gastric dilatation, diagnosis of, 683 
etiology of, 682 
symptoms of, 682 
treatment of, 683 
Addison's disease, and amenorrhea, 581 

in relation to generative organs, 581 
Adeno-carcinoma of uterus, 331, 343 (see also 
Carcinoma of Cervix and Carcinoma of 
Body of Uterus) 
Adenocystoma of kidney, 481 
Adenomyoma, of Fallopian tube, 326 
of recto-vaginal septum, 327 
pathology of, 327 
symptoms of, 327 
treatment of, 328 
of uterus, diagnosis of, 328 
etiology of, 12, 326, 327 
histology of, 327 
pathology of, 327 
symptoms of, 327 
treatment of, 328 
origin of, 12 
Adeno-myosis uteri, 326 
Adenomyositis uteri, 326 
Adhesions, pelvic, treatment of, 641 
Adnexitis, acute, differential diagnosis of, 
from acute appendicitis, 414, 501 
chronic, differential diagnosis of, from 
chronic appendicitis, 503 
Adolescence, hygiene of, 609 
Adrenal gland, extract of, in shock, 670 
in relation to genital organs, 64 
Adrenal tumors of kidney, 481 
Age, in relation to history of pelvic disease, 91 
Alexander operation, in retroversion of 
uterus, 254 
technic of, 260 
Amenorrhea, a symptom of pelvic disease, 98 
etiology of, 580 

factors in, anatomic, 580 
constitutional, 581 
psychic, 581 
general considerations of, 580 
pseudo, 580 
treatment of, 5.81 
Amputation of cervix, 234, 235, 236 
Anaemia, in myomata of uterus, 303, 306, 310, 
616 
in pelvic disease, 87, 106 
risks in operative cases, 615 
treatment of, 616 
Anaesthesia, chloroform in, 649 

combined local and general, 650 

ether in, 649 

ethyl chloride in, 650 

examination of pelvis under, 112, 610 

general considerations of, 649 

local, 650 

727 



728 



INDEX 



Anaesthesia, local, by ethyl chloride, 652 
cocaine in, 650 
eucain in, 650 

solutions for producing, 650 
technic of, in cervix operations, 651 
in celiotomy incisions, 651 
in hysterotomy, 651 
in vaginal operations, 651 
in vulvar incisions, 651 
morphine in, 650, 652 
nitrous oxide and oxygen, 650 
oxygen and ether, 650 
spinal, 652 (see also Spinal Anesthesia) 
Anal, fissure, 522 

fistula, 524 
Anastomosis of intestine, 518, 679, 681 

of ureter, 468 
Animal inoculation in tuberculous disease of 
kidney, in 
in tuberculous cystitis, 456 
Anoci association of Crile, 617, 651 
Anteflexion of uterus, 237, 239 {see also 
Uterus, Pathologic Anteflexion of) 
in dysmenorrhea, 587 
Anterior colporrhaphy, 218 
Antigonococcic serum, 725 

vaccine, 725 
Antistreptococcic serum, 424 
Anus, anatomy of, 45 
diseases of, 522 
examination of, 162 
by inspection, 163 
by palpation, 162 
by specula, 163 
position for, 162 
preparation for, 162 
malformations of, 21 

abnormal communications, 21 
situations, 21 
> absence of, 21 
imperforate, 21 
treatment of, 29 
Appendicectomy, 505 
Appendicitis, acute, 414, 501 

differential diagnosis of, from acute 

adnexitis, 414, 501 
involvement of, in pelvic disease, 500 
symptoms of, 502 
treatment of, 502, 505, 656 
chronic, Bastedo's sign in, 504 
diagnosis of, 503 

differential diagnosis of, from 
• chronic adnexitis, 503 
pathology of, 503 
symptoms of, 503 
treatment of, operations in, 505 
during pregnancy, 656 

Csesarean section in, 656 
Gerster's plan in, 656 
operations in, 656 
suppurative, differential diagnosis of, 
from salpingitis, 414, 501 
drainage in, 660 
relation to pelvic disease, 96 



Appendix, inflammation of, acute, 500 

chronic, 503 
Applications, to Bartholin's gland, 698 
to cervix, 698 
to endometrium, 697 
to Skene's tubules, 700 
to urethra, 700 
to vagina, 698 
Arseno-benzol, in treatment of puerperal 

pelvic inflammatory disease, 424 
Artificial, anus, formation of, 30 
insemination, 606 
menopause, 595 
vagina, formation of, 28 
Arthritis, gonorrheal, 726 
toxic, etiology of, 550 
symptoms of, 550 
treatment of, 550 
Ascites, differential diagnosis of, from 

ovarian cyst, 391, 396 
Aspiration of cystic kidney, 485 
Atresia, 23, 28 (see also Gynatresia) 
Atropin in treatment of dysmenorrhea, 590 

B 

Babcock's method of spinal anaesthesia, 653 
Backache, equilibrium in, 536 
etiology of, 536 

factors in production of, 536, 538 
foci of infection in, 538 
static, 538 (see also Static Backache) 
Bacteriology in cystitis, 453 

in pelvic inflammatory disease, 411 

in pyelitis, 486 

of generative organs, 88, 89 

of pelvis, 88 

of urine, 109 

diagnosis of, by guinea-pig inocula- 
tion, in 
of vagina, 89 
Baldwin's operation for artificial vagina, 28 
Baldy's operation in prolapse of ovary, 410 
in retroversion of uterus, 256, 262 
hsemostasis in, 640 
technic of, 262 
Bartholin's glands, abscess of, 186 
treatment of, 186, 187 
anatomy, 33 
applications to, 698 
cyst of, 187 
inflammation of, 186 
Basedow's disease and amenorrhea, 581 
Bastedo's sign in appendicitis, 504 
Benzyl benzoate in dysmenorrhea, 590 
Beyea's operation for elevation of stomach 

515 
Bimanual examination of pelvic organs, 127 
Biologic theory of carcinoma, 330 
Bladder, abnormal picture of, in cystoscopy, 
146 
anatomy of , 43 

atmospheric distention of, in cystoscopy, 
144 



INDEX 



729 



Bladder, calculus, 458 
capacity of, 43, l 4& 
carcinoma of, 460 
carcinomata of, radium m 721 
care of, after operation, 665 
developmental anomalies of, 21 
absence, 21 
duplication, 21 
extrophy, 21 
fistula, 21 
treatment of, 27 
diseases of, 453 . , _ 

distention of, by water, in cystoscopy, 145 
drainage of, 456, 660 
embryology of, 2 
incisions of, 456 

inflammation of, 453 (see also Cystitis) 
injuries to, 642 

interior of, in chronic cystitis, 147 
local anaesthesia in, 651 
mucosa of, 147 
color of, 147 
transparency of, 147 
new growths of, 459 

treatment of, 460 
orifices of, inspection of, 142 
palpation of, 138 
papilloma of, 460 
papillomata of, radium in, 721 
physiology of, 84 

picture of normal, in cystoscopy, 145 
pillars, 216, 217, 219, 220 
shape of interior of, H7. 
stone, 458 (see also Vesical Calculus) 
tuberculosis of, 456 
ulcer of, Fenwick type of, 459 

Hunner type of, 459 
vessels of, 147 

number of, 147 
position of, 147 
size of, 147 
Block's test for tubercle bacillus in urine, in 

456 . 

Blood count, in pelvic disease, 100 
culture in pelvic disease, 106 
examination of, in pelvic disease, 100 
in pelvic disease, 104, 105 
in peritonitis, 677 

methods of obtaining, for tests, 108 

pressure risks in operative cases, 616 

Crile's anoci association in, 617 

urea, methods for determining, 160 

test, 160 

Blood-vessels of generative organs, 54 

of pelvis, 54 
Bowels, post-operative care of, 664 

enemas for, 664 
Breast, in relation to generative organs, 65 
Brodel's white line in kidney, 484 
Bronchitis, post-operative, etiology of, 683 
symptoms of, 684 
treatment of, 684 
Byrne's treatment of carcinoma of cervix 
"with cautery knife, 354 



Csesarean section in pregnancy with appen- 
dicitis, 656 . 
Calculus of bladder, 458 (see also Vesical 
Calculus) . 
of kidney, 478 (see also Renal Calculus) 
of ureter, 489 (see also Ureteral Cal- 
culus) 
Canal of Nuck, 48 

hydrocele of, 187 
Carcinoma of bladder, 460 
diagnosis of, 460 
symptoms of, 460 
treatment of, 460, 461 
of body of uterus, 342 

diagnosis of. 344. 

curettement in, 345 
digital exploration, 345 
instrumental exploration, 

345 ... 

microscopic examination m, 

345 
extension of, 343 
lymphatic involvement in, 343 
myoma with, 343 
pathology, 34 2 
precancerous changes in, 343 
prognosis in, 345 
spread of, 343 
symptoms of, 344 
cachexia in, 344 
hemorrhage in, 343 
leucorrhcea in, 344 
treatment, 345 

hysterectomy, 345 
abdominal, 345 
vaginal, 345 
palliative measures, 340 
panhysterectomy in, 345 

preliminary treatment 
in, 345 
radium in, 717 
of cervix, clinical forms of, 334 
cauliflower, 334 
excavating, 335 
indurated, 335 
infiltrating, 335 
proliferating, 334 
ulcerating, 336 
vegetating, 334 
diagnosis of, 336 

by inspection, 338 . 

by microscopic examination, 338 
differential diagnosis of, from ever- 
sion and erosion, 338 
from myomata, 339 
from polyps, 339 
from sarcoma, 339 
from syphilis, 339 
from tuberculosis, 339 
extension of, 33L 332, 334 . 
involvement of lymphatics in, 332, 

334 
of surrounding tissue in, 332, 334 



730 



INDEX 



Carcinoma of cervix, metastasis of, 334, 335 
operability of, 340 
pathology of, 331 

columnar-cell type, 331 
squamous-cell type, 331 
prognosis in, 340 

American statistics, 340 
European statistics, 340 
five-year period, 340 
question of operability in, 340 
radium in, 714 
recurrence of, after operation, 342 

symptoms of, 342 
symptoms, 335 

hemorrhage, 336 
cause of, 336 
leucorrhcea, 336 
pain, 336 
treatment, 339 

destructive cauterization in, 353 
high amputation with cautery 

knife, 354 
hysterectomy, 340 
abdominal, 340 
vaginal, 340, 351 

with paravaginal in- 
cisions, 352, 353 
inoperable cases, 341 
cautery, 342 

Percy method, 341, 342, 35b 
radium, 341 
Rontgen ray, 341 
operations in, 339 
panhysterectomy, 339, 349 
Percy method, 354 
technic of, 356 
of Fallopian tube, 368 
of ovary, 395 (see also Ovary, Carci- 
noma of) 
of rectum, 534 
diagnosis, 534 
etiology, 534 
symptoms, 534 
treatment, 534 

operations for, 534 
radium in, 534, 722 
varieties, 534 
of urethra, 451 

symptoms of, 451 
treatment of, 451 

Crossen's plan in, 45i 
of uterus, etiology, 330 
age in, 330 

biologic theory in, 330 
childbirth in, 330 
heredity in, 330 
race in, 330 

relative frequency of, 330 
pathology, 331 
recurrence, 342 
relation to menopause, 594 
situation, 330 
of vagina, 196 
primary, 196 
treatment, 196 



Carcinoma of vulva, 181 
diagnosis, 182 
symptom, 181 
treatment, 182 

radium in, 721 
Cardiac condition in pelvic disease, 105 

complications in myomata of uterus, 303, 

306 
dilatation, post-operative, 690 
etiology, 690 
symptoms, 690 
treatment, 691 
risks in operative cases, 615 

anaesthesia in, 615 
complications in, 303, 306, 

615 
posture in, 615 
treatment of, 615 
Caruncle of urethra, 449 (see also Urethral 

Caruncle) 
Cases, record of, form for, 92 
Catgut, preparation of, for operation, 622 
Cathartics, use of, after operations, 665 
Catheter, bismuth, 156, 491 
self -retaining, 446 
shadow, 156 
sty letted, 491 
ureteral, 143 

sterilization of, 143 
wax-tipped, 150 
Catheterization after operation, 666 

of ureters, 147 
Causes of pelvic disorders, 87 
acquired, 88 
congenital, 87 

evident at birth, 87 
at menopause, 87 
at puberty, 87 
in reproductive period, 

8 7 
Cauterization of cervix, 353, 354 

Cautery, electro, 704 

thermo, 704 
Cellulitis, pelvic, 430 
chronic, 432 

diagnosis, 432 
etiology, 432 
pathology, 432 
symptoms, 432 
treatment, 432 

pelvic massage in, 433 
vaginal tampons in, 433 
diagnosis of, 431 
etiology of, 430 
pathology of, 430 
symptoms of, 431 
treatment of, 432 
Cervix, amputation of, 234 
high, 234 
low, 234 
atresia of, 24, 28, 223 
carcinoma of, 331 (see also Carcinoma of 

Cervix) 
catarrh of, 227 
chancre of, 572 



INDEX 



731 



Cervix, conical, 28 

cystic degeneration of, 228, 230 
dilatation of, 120 
diseases of, 223 
elongation of, 228, 229 
endometrium of, inflammation of, 223 
hyperplasia of, 223 
infections of, 223 
erosion of, 228 
eve rs ion of, 227 
excision of, test, 121 
gonorrhoea of, 224 
hypertrophic elongation of, 229 
hypertrophy of, 229 
infection of, treatment of, 224 
lacerations of, 226 

amputation for, 234 
causes of, 226 
diagnosis of, 230 
results of, 227-229 
symptoms of, 229 
tracfielectomy for, 234 
trachelorrhaphy for, 233 
treatment of, 231 

operative measures in, 232 
palliative measures in, 232 
varieties of, 226 
local applications to, 698 
Nabothian cysts of, 228 
obliteration of, in labor, 79 

in pregnancy, 79 
operations on, local anaesthesia in, 652 
polyp of, 225 

etiology of, 225 
symptoms of, 226 
treatment of, 226 
softening of, in pregnancy, 76 
stenosis of, 28 

treatment of, 28 
supravaginal elongation of, 267 
syphilis of, 572 
tuberculosis of, 566 
vaginal elongation of, 229 
Chancre of vulva, 174 
Chancroid of vulva, 176 

treatment of, 177, 178 
Childbirth, in relation to pelvic disease, 95 
Chloroform anaesthesia, 649 
Chromo-cystoscopy, by indigo carmine, 158 
Chromo-ureteroscopy, technic of method of, 

159 
Chronic pelvic inflammatory disease, 428 
diagnosis of, 429 
etiology of, 428 
pathology of, 428 
symptoms of, 429 
treatment of, 430 
Chorioepithelioma of uterus, 346 
diagnosis, 348 
etiology, 347 

hydatidiform mole in, 347 
metastasis of, 347 
pathology, 346 

ovarian cysts with, 348, 404 



Chorioepithelioma of uterus, prognosis, 348 
situation of, 348 

abnormal, 348 
symptoms, 348 

hemorrhage, 348 
tumor, 348 
treatment, 349 
of vagina, 197 
Chorion, 73 

frondosum, 75 
villi of, 73 
Circulatory symptoms, in myomata, 302, 303, 
306 
in pelvic disease, 101, 105 
Clark's theory of histogenesis of ovarian 

cysts, 384 
Climacteric, 82, 94 
Clitoris, 33 

Coccygodynia, diagnosis of, 552 
etiology of, 552 
symptoms of, 552 
treatment of, 552 
Coccyx, injuries to, 552 

Coffey operation in retroversion of uterus, 
258 
technic of, 261 
Colon, disorders of, in intestinal stasis, 509 

operations on, 515 
Colopexy, 515 

Colporrhaphy, anterior, 216 
posterior, 209, 210, 213 
Complaint, chief, 91 
Complete tear of perineum, 202 {see also 

Perineum, Injuries to) 
Condylomata acuminata, 178 
treatment of, 179 
lata, 175 

of vulva, 571 
Congenital causes of pelvic disease, 87 
Conservation of adnexa, 312, 324, 640 
Constipation, as symptom of pelvic disease, 
100 {see also Chronic Intestinal Stasis), 507 
Corpus luteum, 66 

cysts of, 403 
formation of, 70 
of menstruation, 69 
of pregnancy, 76 
Corsets, features of good, 696 

use of, 696 
Crile's anoci association, 617, 651 
Crossen's plan in carcinoma of urethra, 451 
Crown sutures, 209, 211, 213 
Curettement, diagnostic, 121 
findings in, 289 
in carcinoma of cervix, 339 
in endometritis, 280 
preservation of tissues from, 291 
results of, 289 
technic of, 289 
Curettings, preservation of, 291 
Cutaneous diseases of external genitalia, 166 
Cystadenoma of ovary, 384 
Cystic degeneration of ovary, 383 
tumors of kidney, 480 



732 



INDEX 



Cystitis, 453 
acute, 453 

diagnosis of, 453 
etiology of , 453 

prognosis of, 454 

symptoms of. 453 

treatment of, 454 
bacteriology in, 453 
chronic, 454 

diagnosis, 455 

etiology, 454 

symptoms, 454 

treatment, 456 

operations in, 456 
drainage in, 660 
etiology of, 453 
post-operative. 690 
tuberculous, 456 

chromocystoscopy in, 456 

cystoscopic findings in, 456 

diagnosis of, 456 

animal inoculations in, in, 456 

etiology of. 456 

symptoms of. 456 

treatment of, 458 

ureteral orifices in, 456 
Cystocele, diagnosis of, 216 

mode of production of, 202 
operations for, 216 

Goffe's, 220 

interposition of uterus, 220 

large cystocele, 220 

Martin's. 216 

Sanger's, 216 

Watkins', 220 
treatment of, 216 
Cystopexy, 216 

Cystoscopes, sterilization of. 143 
Cystoscopy, abnormal appearance of bladder 
in. 146 
appearance of bladder in, 145 
atmospheric distention of bladder in, 144 
direct method, 144 

distention of bladder by water in. 145 
general preliminaries to, 143 
in diagnosis of ureteral fistula, 465 
indirect method. 145 
in kidney functional tests, 158 
in tuberculous cystitis, 457 
Kelly's method, 144 
landmarks in, 144 

locating fixed anatomical points in, 145 
position for. 145 
ureteral calculus, 491 
urinary fistula, 465 
Cystotomy, 456, 459 



Decidua. 72 

cells, 72 

compacta, 72 

serotina, 75 

spongiosa. 72 
Deciduoma malignum, 346 (see also Chorio- 
epithelioma of Uterus) 



Defecation, difficult, in rectocele, 204 

mechanics of, 85 
Delayed menstruation, 580 
Dermoid cysts of ovary, 383 
Descensus uteri, 238 

Developmental anomalies of generative or- 
gans, 15 

defects in etiology of dysmenorrhcea, 587 
in etiology of sterility, 599 
Diabetes in pruritus vulva, 170 
Diagnostic curettement, 121 
Diet after operations, 664 
Dilatation of bladder, 145, 458 

cervix in treatment of dysmenorrhcea, 591 

heart, post-operative, 690 

stomach, acute, post-operative, 682 
Disorders of menstruation, 579 
Diverticulitis, etiology of, 520 

symptoms of, 520 

treatment of, 520 
Doderlein. bacillus of, 89 
Doran's theory of histogenesis of ovarian 

cysts, 384 
Dorsal position, 113 
Douche, vaginal, the, 706 
Douglas, pouch of, 46 

incision of, 652, 659 
Drainage, as protective pack, 657 

general considerations of, 657 

in appendicitis, 659 

in bladder, 456, 660 

indications for. 659 

in gall-bladder, 659 
techmc of, 660 

in gall-duct, 659 

in kidney, 660 

in pancreas, 660 

in peritonitis, 659 

method of closing incision in drainage 
cases, 646 

position of patient to favor, 658 

post-operative care of, 660 

purpose of. 657 

technic of abdominal. 647 

through Douglas' cul-de-sac, 659 

vaginal, 659 

when placed in pelvis, 639 
Dressings, preparation of, for operation, 622 
Duct, gall, 660 

Gartner's, 9 

Miillerian, 1 

Skene's, 34 

Wolffian, 1 
Ductless glands, relation to genital organs, 

63. 595 
Dudley's operation in pathologic anteflexion 

of uterus, 243 
Dysmenorrhcea, 87, 587 

etiology of, 587 

acquired lesions in, 589 
anteflexion of uterus in, 588 
congenital defects in. 587 
developmental defects in, 588 
gynatresia in, 589 

extragenital manifestations in, 587 



INDEX 



733 



Dysmenorrhea, headache in, 587 
in endometritis, 279 

in pathologic anteflexion of uterus, 240 
in relation to disease, 94 
in retroversion of uterus, 247 
in symptomatology, 98 
interval, 592 
membranous, 592 
etiology of, 592 
treatment, 591 
menstrual molimina in, 587 
mental features in, 589 
stenosis of cervix in, 588 
treatment of, 589 
atropin in, 590 
benzyl benzoate in, 590 
dilatation of cervix in, 591 
electrical treatment in, 591 
general considerations in, 590 
nasal treatment in, 590 
Norris drain in, 591 
operations in, 591 
abdominal, 591 
on cervix, 591 
on ovary, 591 
on vaginal wall, 591 
ovarian therapy in, 590 
Dyspareunia, 172, 194, 601 



E 

Echinococcus cysts of kidney, 481 

Ectopic pregnancy, 370 (see also Extrauterine 

Pregnancy) 
Edebohl's suspension of kidney, 482 
Electricity, uses of, in gynecology, 701 
Electrocauterization in bladder tumors, 460 
Electrocautery, 704 
Elephantiasis of vulva, 173 
Embolism, pulmonary, 688 
Embryologic structures, 1 
Embryology, 1 

Embryonic rests and new formations origi- 
nating in them, 8, 88, 327, 330, 384, 385, 
388, 391, 395. 
Emmet, operation for lacerated cervix, 2^3 

perineum, 210 
Empyema of kidney pelvis, 471 (see also 

Pyelonephritis) 
Endocervicitis, 223 
symptoms of, 224 
treatment of, 224 
Endometrial cavity, curettement of, in gonor- 

rhceal pelvic inflammatory disease, 417 
Endometritis, acute, 277 
diagnosis of, 278 
etiology of, 277 
gonococcus on, 277 
pathology of, 278 
symptoms of, 277 
treatment of, 278 
chronic, 278 

diagnosis of, 279 
etiology of, 278, 279 
pathology of, 279 



Endometritis, chronic, symptoms of, 279 
treatment of, 279 

curettement in, 280 
local applications in, 280 
cystic glandular, 279 
fungous, 279 
glandular, 279 
polypoid, 279 
Endometrium, 39 

application to, 698 
changes of, in myomata, 295 
histology of, in inflammation of, 278 
inflammation of, 277 (see also Endome- 
tritis) 
menstrual changes in, 67 
polyps of, 280 

degenerations of, 280 
diagnosis of, 281 
pathology of, 280 
symptoms of, 280 
treatment of, 281 
tuberculosis of, 564 
Endosalpingitis, 359, 360 

end results of, 361 
Enemas, for post-operative care of bowels, 

664 
Enteroclysis, post-operative, 663 
continuous, 668 
interrupted, 668 
solutions used in, 667 
Enteroptosis, 507 

midline ptosis, 508 
partial, 508 
treatment of, 512 
Epispadias, 21, 27 
Epoophoron, 13 

Equilibrium, antero-posterior, 536 
centre of gravity in, 537 
disturbances of, 538 
joints concerned in, 537 
lateral, 536 
mechanics of, 536 
muscles concerned in, 538 
Esthiomene, vulva, 184 
Ether anaesthesia, 649 
Ethyl chloride, anaesthesia by, 650 

local anaesthesia by, 652 
Examination of abdomen, 112 

general physical, in pelvic disease, 103 
of anus, 162 

of blood, in pelvic disease, 106 
of patients, preparatory to operation, 614 
general, 614 
local, 614 
of pelvis, 112, 125 

instruments for, 119 
local physical, 112 
preparation for, 113 
special methods of, 119 
under anaesthesia, 112 
of rectum, 162 
of urine, bacteriologic, no 
in pelvic disease, 108 
for tubercle bacillus, in 
Excretions, the, of the genitalia, 83 



734 



INDEX 



Exercises for ptotic patients, 511, 512 
Exfoliative dysmenorrhcea, 592 
Exploratory celiotomy, 639 

laparotomy, 591, 639 
External genitalia, 25 (see also Genitalia, Ex- 
ternal) 
Extrauterine pregnancy, abdominal preg- 
nancy in, 372-377 
diagnosis of, 377 
with lithopedion formation, 372 
diagnosis before rupture, 375 
at rupture or abortion, 376 
of abdominal pregnancy, 377 
of hematocele formation, 376 
etiology of, 369 

factors concerned in, 370 
fate of the ovum in, 372 

of the pregnant tube in, 374 
hematocele formation in, 373, 377 
hematoma in, 433 

etiology of, 433 
hemorrhage in, 373 

pelvic hematocele in, 373, 377 
intraperitoneal bleeding in, 373 
multiple pregnancy in, 370 
pathology of, 371 

nidation of the ectopic ovum, 371 
prognosis of, 377 
symptoms of, abortion, 374 

case of abdominal pregnancy, 

375 
previous to tubal rupture, 374 
tubal rupture or abortion, 375 
treatment of, 378 

at time of rupture, 378 
early, 378 

of abdominal pregnancy, 379 
of old cases, 379 
time of operation in, 378 
vaginal puncture in, 379 
tubal abortion in, 371 
rupture in, 371 

fate of ovum in, 372 
uterine changes in, 374 
varieties of, 370 
abdominal, 370 
ampullar, 370 
interstitial, 370 
isthmic, 370 
ovarian, 370 
tubo-ovarian, 370 
Extraperitoneal operations in urinary fistula, 
468 

F 

Fallopian tubes, adenomyoma of, 326, 327 
anatomy of, 40 
at birth, 8 
carcinoma of, 368 
cysts of, 367 
developmental anomalies of, 15 

absence, 15 

accessory ostia, 15 

diverticula, 15 

fcetal type, 15 



Fallopian tubes, developmental anomalies in, 
partial development of, 15 
supernumerary, 15 
diseases of, 359 
embryology of, 2 
embryomata of, 367 
enlargements of, 368 

accidents affecting, 368 
rupture of, 368 
torsion of, 369 

symptoms of, 369 
treatment of, 369 
excision of, 437 

inflammation of, 359 (see also Sal- 
pingitis) 
myomata of, 367 
new formations of, 367 
operations on, 436-438 
papillomata of, 367 
physiology of, 62 
polyps of, 367 

pregnancy in, 369 (see also Extra- 
uterine Pregnancy) 
resection of, 418 
syphilis of, 574 
tuberculosis of, 561 
Family history, in relation to pelvic disease, 95 
Faulty posture, types of, 539 
gorilla, 539, 541 
kangaroo, 539, 541 
overfeminine, 539 
slumped visceroptotic, 539 
Fecundation, 71 

Female pseudohermaphrodism, 22 
Fenwick type of bladder ulcer, 459 
Fibroid tumors of uterus, 295 (see also 

Myomata of Uterus) 
Fibromata of ovary, 396 
Fibromyoma of vulva, 185 
Fibrosis uteri, 283 
Fissure in ano, 522 

diagnosis of, 522 
symptoms of, 522 
treatment of, 523 

divulsion of sphincter, 523 
operation for, 523 
of urethra, 445 
Fistula in ano, 524 

diagnosis of, 525 
symptoms of, 525 
treatment of, 525 

operations for, 525 
urinary, 463 (see also Urinary Fistula) 
vesico-umbilical, 21 
Fluid, menstrual, 66 
Flushing at menopause, 594 

infections in etiology of, oophoritis, 381 
post-operative parotitis, 691 
urethritis, 444 
toxic arthritis, 550 
Fcetal structures, 1 
Follicles, Graafian, 9, 69 

maturation of, 9, 69 
Form for history, 92 






INDEX 



735 



Fornices, vaginal, 34 

anterior, 35 

posterior, 35 
Fossa navicularis, 32 
Fourchette, 33 
Fowler, bed, 668 
position, 669 
Frankl's theory, of cystic degeneration of 
ovary, 402 

of histogenesis of ovarian cysts, 384 
Frazier's operation for ptosis of colon, 516 
Figuration in bladder tumors, 460 
Fundus of uterus, 37 

carcinoma of, 342 



Gall-bladder, drainage of, 659 

post-operative care of, 661 
Galvanism in treatment of dysmenorrhcea, 

591 
Gartner's duct, 9, 13 

Gastric dilatation, acute post-operative, 682 
Gastro-intestinal symptoms in pelvic disease, 

100 
Gastropexy, 515 
Gauze drains, 647 

pads, in isolation of operative area, 637 

use of, in abdominal surgery, 648 
Gelhorn's method of using heat in treatment 

of pelvic disease, 701 
General health in pelvic disease, 101 
Generative organs, anatomy of, 31 

anomalies of, 15 

changes of, in pregnancy, 75, 78 

developmental anomalies of, 15 

embryology of, 1 

excretions, the, of the, 83 

physiology of, 61 

relation of, to glands of internal 
secretion, 63-65 

syphilis of, 569 

tuberculosis of, 560 (see also Tuber- 
culosis of Generative Organs) 
Genital fistula, 463 

Genitalia, external, abnormalities of, 25 
treatment of, 2j 

anatomy of, 31 

cutaneous diseases of, 166 

developmental anomalies of, 20 

diseases of, 166 

embryology of, 2 

hernia in, 189 

herpes of, 166 

injuries of, 188 

malformations of, 20 
diagnosis of, 25 
treatment of, 27 

parasitic diseases of, 166 

pediculosis of, 166 

physiology of, 62 

ringworm of, 166 

venereal conditions of, 173 
Genito-urinary system, 440, 453, 469 
Gestation (see Pregnancy) 



Gland of Bartholin, 33 (see also Bartholin's 
Glands) 
mammary, 65 

of internal secretion, 63-65 
parathyroid, 64 
pineal, 65 
pituitary, 63 
sexual, 1, 42 
suprarenal, 64 
thyroid, 64 
Glands of internal secretion in premature 

menopause, 595 
Glans clitoris, 33 

Gloves, preparation of, for operation, 622 
Glycosuria, in pruritis, 170 
Goitre in women, 64 
Gonococcus, characteristics of, 554 
diagnosis of, 123 
examination of smears for, 556 
immunity to, 554 
in endometritis, 277, 278 
infection from, in chronic cases, 554 
in pelvic inflammatory disease, 411 
latency of, 555 
lesions due to, 554 
mode of invasion, 89 
smear preparation in, 124 
staining of, 124 

technic of preparation of smears for, 556 
glass slides in, 556 
time of obtaining, 557 
Gonorrhoea, cause of endometritis, 277 
complement-fixation test for, 107 
diagnosis of, 556 

gonococcus in, 556 
smears in, 556 
symptomatology in, 555 
douches in, 556 
general peculiarities, 554 
latent, 556 

pelvic inflammation due to, 554 
prognosis of, 558 

in acute cases, 558 
in chronic cases, 558 
prophylaxis of, 558 

education in, 559 
residual, 555 
sterility due to, 554 
symptoms of, 555 

localization of lesions, 556 
macules in, 556 
mildness of, 555 
seat of initial attack, 555 
smears in, 556 
treatment, 559 
Gonorrhceal arthritis, 725 
macules, 556 

pelvic inflammatory disease, conservation 
of adnexa in, 418 
diagnosis of, 414 
differential diagnosis of, 414 
from appendicitis, 414 
puerperal inflammatory 
disease, 415 
etiology of, 412 



736 



INDEX 



Gonorrhceal pelvic inflammatory disease, hys- 
terectomy in, 417 
technic of, 417 
pathology of, 412 
results of, 414 
symptoms of, 414 
treatment of, 415 
acute, 415 
cauterization in, 417 
chronic stage, 416 
curettement in, 417 
hysterectomy in, 417 

technic of, 417 
palliative measures in, 

415 
resection of ovary in, 

418 
sera in, 725 
subacute stage, 416 
time of operation in, 415 
vaccines in, 726 
vaginal douches in, 415 
puncture in, 416 
Gorilla type of faulty posture, 539, 541 

treatment of, gymnastic, 546 
mechanical, 546 
supportive, 546 
Graafian follicle, cysts of, 402 
development of, 9, 69 
Grafts, ovarian, 606 

Graves' disease in relation to generative or- 
gans, 64 
Gumma of vulva, 571 
Gynatresia, 23, 89 

diagnosis of, 25-27 
in dysmenorrhcea, 588 
symptoms of, 23 
treatment of, 27 
Gynecologic postures, 113 

H 

Habit, the menstrual, 579 

Habits of life, in relation to disease, 93 

Hematocele in extrauterine pregnancy, 373 

Hematocolpos, 24 

Hematogenous infections in oophoritis, 381 

in pyelonephritis, 471 
Hematoma of pelvis, diagnosis of, 433 
etiology of, 433 
prognosis, 433 
symptoms of, 433 
treatment of, 433 
of vulva, 180 
Haematometra, degenerations of, 288 
etiology of, 288 
symptoms of, 288 
treatment of, 288 
Hematosalpinx, 24, 367 
Hematotrachelos, 24 
Hematuria in tuberculosis of kidney, 475 
Hemostasis, 640 

Hands, preparation of, for operation, 622 
Headache, as symptom of pelvic disease, 99 
in dysmenorrhcea, 587 



Heart, disease of, in operative cases, 615 (see 
also Cardiac Risks) 
dilatation of, post-operative, 690 
in myomata, 303, 306 
in pelvic disease, 105 
Heat, in treatment of pelvic inflammatory 

disease, 700 
Hegar's sign of pregnancy, 76-79 

operation for lacerated perineum, 211 
Hemorrhage, arterial, 671 

after abdominal operations, 671 
diagnosis, 672, 673 
symptoms, 672 
treatment of, 673 
after plastic operations, 672 
capillary oozing, 671 
in ectopic pregnancy, 373 
intraperitoneal, 373 
menstrual, mechanics of, 66 
post-operative, varieties of, 671 
venous, 671 
Hemorrhagic uteri, radium in, 720 
Hemorrhoids, diagnosis of, 528 
pathology of, 527 
symptoms of, 527 
treatment of, 528 

operations in, 529 
Heredity in etiology of carcinoma of uterus, 

330 
Hermaphrodism, 22 
Hernia, of ovary, 409 
of rectum, 531 
of uterus, 238 
perineal, 189 
pudendal, 189 
Herpes, of genitalia, 166 
History taking, 91 

form of record, 92 
family, in relation to pelvic disease, 

95 
general previous, to pelvic disease, 96 
menstrual, in relation to disease, 94 
Hodge pessary, 701 
Hot flashes at menopause, 594 
Hiihner's method in diagnosis of sterility, 601 
Hunner type of bladder ulcer, 459 
pathology of, 459 
treatment of, 460 
Hydatid, stalked, of Morgagni, 10, 367 
Hydatidiform mole, in etiology of chorio- 
epithelioma, 347 
-like structure in cyst of ovary, 399 
recognition of, 290 
Hydrocele of canal of Nuck, 187 
Hydronephrosis, 470 
diagnosis, 471 
etiology, 470 
pathology, 470 
treatment, 471 
Hydrops folliculi, 402 

tube profluens, 367, 593 

in dysmenorrhea, interval type, 592 
Hydrosalpinx, 360, 365 
etiology of, 365 
follicularis, 366 



INDEX 



737 



Hydrosalpinx, rupture of, 368 
simplex, 366 
torsion of, 369 
Hygiene of adolescence, 609 
Hymen, developmental anomalies of, 20 
atresia, 20 
double, 20 
diseases of, 192 

abnormal elasticity of, 192 
cystic tumors of, 192 
rigidity of, 192 
Hyperinvolution of uterus, 286 
etiology of, 286 
symptoms of, 287 
treatment of, 287 
Hypernephromata, origin of, 13 
relation to pelvic disease, 64 
Hypertension in operative cases, 616 
Hypertrophy of cervix, 229 
Hypospadias, 21, 27 
Hvposuprarenalism, relation to pelvic disease, 

64 
Hypotension in operative cases, 616, 617 
Hysterectomy, abdominal, 317 
bisection of uterus in, 436 
for carcinoma of uterus, 340, 345 
for myomata, 317 

for pelvic inflammatory disease, 433 
vaginal, 340, 345, 351 

for carcinoma of uterus, 340, 345 
for myomata of uterus, 351 
with paravaginal incisions, 352, 353 
variations in technic of, 434 
Hysterocele, 238, 263 
Hysteromyomectomy, 317 
Hysteropexy, 257, 260 
Hysterotomy, local anaesthesia in, 651 



Ileus, adynamic, 678, 682 
dynamic, 678, 682 
mechanical>678, 682 
paralytic, 678, 682 
Illumination for pelvic examination, 118 

with head mirror, 118 
Incisions for abdominal operations, 624 
technic of, 635 
directions regarding, 633 
dressing, 646 

for kidney operations, 630 
post-operative care of, 669 
suppuration of, post-operative, 689 

treatment of, 689 
technic of closing, 644 

in drainage cases, 646 
Incontinence of urine, 447, 448 
Indigo-carmine in kidney function tests, 158 
Infectious diseases, relation of, to pelvic dis- 
eases, 93 
Insanity, as a post-operative complication, 612 
at_ menopause, 595 
etiology of, 612 
in relation to gynecology, 611 
47 



Insanity, types of, benefited by operation, 612 

not benefited by operation, 611 
Insemination, 71 

artificial, 606 
Instruments for pelvic examination, 119 
Intermenstrual pain, periodic, 592 
Internal secretion, glands of, in premature 
menopause, 595 
in relation to generative organs, 
63-65 
Interposition operation for cystocele, 220 
of Watkins, 220 
for prolapse of uterus, 272 
of Watkins, 272 
Interval dysmenorrhea, 592 
Intestinal obstruction, acute, 505, 678 
causes of, 678 
diagnosis of, 680 
etiology of, 678 
pathology of, 678 
forms of, 678 
post-operative, 678 
symptoms of, 679 
treatment of, 681 
operative, 681 
stasis, acute, 505 

chronic, from pelvic disease, 507 

diagnosis of, 511 
from adhesions between intestines 
and peritoneum, 510 
intestinal loops, 510 
the mesenteries, 510 . 
the mesentery and 
omentum, 510 
from enteroptosis, 507 
from kinking of colon, 509 
from redundancy of colon, 509 
from overdistention of colon, 509 
symptoms of, 511 
treatment, 512 
dietetic, 512 
medical, 513 
postural, 512 
surgical, 515 

Beyea's operation, 515 
Coffey's operation, 516 
colopexy, 515 

contraction of the abdomi- 
nal parietes, 520 
division of adhesions, 516 
gastropexy, 515 
intestinal anastomosis, 518 
resection of the intestine, 

519 
Wilms' operation, 516 
Intrauterine tampon, 705 
Involution of uterus, 285 
Israel's kidney incision, 632 

K 

Kangaroo type of faulty posture, 539, 541 

treatment of, gymnastic, 546 
mechanical, 546 
supportive, 546 



738 



INDEX 



Kelly's kidney incision, 630 
Kidney, absence of, 21 
rudimentary, 21 

abscess, 471 (see also Pyelonephritis) 
drainage in, 660 
post-operative care of, 661 
adenocystoma of, 481 
adrenal tumors in, 481 
aspiration of, 485 
Brodel's white line in, 484 
calculus, 478 (see also Renal Calculus) 
cystic tumors of, 480 
diseases of, 469 
echinococcus cysts of, 481 
Edebohl's suspension of, 482 
embryology of, 3 
empyema of pelvis of, 471 
examination of, with wax-tipped bougie, 

150 
foetal type, 21 

functional activity of, estimation of, 158, 
619 
blood urea test of, 160 
by chromocystoscopy, 158 
by chromoureteroscopy, 159 
combined, 158 
by indigo-carmine, 158 
by phenolsulphonephthalein, 159 
separate, 158 
horseshoe, 21 
hydronephrosis of, 470 
incisions for exposure of, 481 

directions regarding, 633 
Israel's 632 
Kelly' £, 630 
Mayo-Robson's, 632 
Mayo's, 631 
infection of, post-operative, 689 
inflammation of, post-operative, 684 
lithotomy, 483 
malformations of, 21 
movable, 469 
nephropexy, 483 
nephrotomy, 483 
nephrectomy, 484 

operation technic in treatment of, 481 
palpation of, 138 
pararenal tumors with, 481 
pelvis, lavage of, 488 
percussion of, 140 

punch, Murphy's, 140 
trimanual method of, 139 
polycystic disease of, 480 
ptosis of, 509 
pyelitis, 485 
pyelonephritis, 471 
pyelonephrosis, 471 
pyelotomy, 483 • 
risks in operative cases, 618 (see also 

Urinalysis) 
Rontgenographic examination of, 151 
percentage of error in, 153 
source of error in, 153, 155 
stone, 478 (see also Renal Calculus) 
diagnosis of, 150 



Kidney, suspension of, 482, 483 

tuberculosis of, 473 

tumors of, 480 

white line in, 484 
Knee-chest position, 114, 115 
Kobelt's tubules, 11 
Kraurosis of vulva, 172 
Kruckenberg tumor of ovary, 397 



Labia, majora, anatomy of, 32 

minora, anatomy of, 33 
hypertrophy of, 20 
Labor, 79 

in relation to pelvic disease, 95 
Lacerations of cervix, 226 

perineum, 201 
Lane's kink, 510 
Langhan's layer, ys 
Lavage of kidney pelvis, 488 
Leucocytosis in pelvic disease, 106 

in peritonitis, 677 
Leucorrhcea, as symptom of carcinoma, 344 
of endometritis, 279 
of metritis. 283 
of pelvic disease, 99 
of retroversion of uterus, 246 

bacteriology of, 198 

definition of, 197 

etiology of, 197 

lactic acid bacillus, treatment of, 198 

treatment of, 198 

vaccines in, 199 
Levator ani muscle, 50 

function of, 200 
laceration of, 201 
Ligaments of uterus, 46 

of ovary, 42 

of pelvis, 46 

triangular, 53 
Lochia, 81 
Lubricant, 117 
Lungs, in pelvic disease, 106 

disease of, post-operative, 684 
Lupus, of vulva, 182 
Lutein cystoma ovarii, 404 
Lymphatics of external genitalia, 60 

of pelvis, 58 

of uterus, 60 

of vagina, 60 
Lymph-nodes, pelvic, 58 

hypogastric, 59 

iliac, 58 

inguinal, 59 

internal iliac, 59 

sacral, 59 

M 

Maculae gonorrhceica, 556 
Male pseudohermaphrodism, 23 
Mammary gland, relationship of, to genera- 
tive organs, 65 
Martin's operation for cystocele, 216 
Mayo's kidney incision, 631 
Mayo-Robson's kidney incision, 632 



INDEX 



739 



McBurney's incision, 627 

Meatus, urinary, 43 

Mechanics of normal support of perineum, 

200 
Meckel's diverticulum, inflammation of, 5 20 
Menge pessary in descensus of uterus, 270, 

703 
Menstrual cycle, 65-70 
fluid, 66 

source of, 40 
habit, 66, 579 

variations of, in pelvic disease, 

94 

history in pelvic disease, 94 

molimina, 580 

symptoms in pelvic disease, 98 
Menstruation, absence of, 580 

anatomic changes incident to, 66 
cessation of, 580 
delayed, 580 
disorders of, 579 
false, 23 

mechanics of, 66 
pain in intervals between, 592 
painful, 587 
phenomena of, 65 
precocious, S79 

relationship of, to ovulation, 66-69 
retarded, 580 
vicarious, 580 

with expulsion of membrane, 592 
Mental features in dysmenorrhcea, 589 
Menopause, 82, 94 
age of, 82 
artificial, etiology of, 83, 595 

ovariectomy in, 595 

symptoms of, 596 
vasomotor, 596 
neurotic, 596 

treatment of, 596 

ovarian therapy in, 596 
blood-pressure changes at, 594 
changes in ovaries in, 82 
menorrhagia at. 594 
mental changes in, 594 
metrorrhagia at, 594 
nervous manifestations in, 83 
premature, 83, 594 

etiology of, 594 

gland of internal secretion in, 595 

treatment, 595 
relation to carcinoma, 594 
symptoms of, 594 
time of, 593 
Menorrhagia, as symptom of endometritis, 
279 

of pelvic disease, 99 

of retroversion of uterus, 246 
etiology of, 583 
in metritis, 283 
in myomata, 303 
treatment of, 584 
Metritis, acute, 282 

symptoms of, 282 

treatment of, 282 



Metritis, chronic, 282 

diagnosis of, 284 
etiology of, 282 

syphilis in, 282 
pathology of, 283 
symptoms of, 283 
treatment of, 284 
Metrorrhagia, as symptom of endometritis, 
279 
of pelvic disease, 99 
of retroversion of uterus, 246 
etiology of, 585 
in metritis, 283 
in myomata, 303 
treatment of, 586 
Micturition (see Urination) 
Miscarriage, 79 
Mittelschmerz, 592 
Mole, hydatidiform, with ovarian cysts, 404 

in etiology of chorioepithelioma, 347 
Molimina menstrualis, 580, 587 
Morgagni, stalked hydatid of, 10 
Morphine as preanesthetic agent, 650, 653 
Movable kidney, 469 
Miillerian duct, 1 

failure of fusion of, 16-19 

in etiology of adenomyoma, 327 
Multiple operations, 655 
Murphy button, 682 

kidney punch, 140 
Myomata of uterus, blood supply of, 293 
carcinoma of uterus with, 300 
changes in uterus in, 295 
of endometrium, 295 
of muscular wall, 295 
choice of operation in, 311 
circulatory lesions in, 302 
ansemia, 303 

cardiac degeneration, 303 
dilatation, 303 
murmurs, 303 
palpitation, 303 
thrombosis, 303 
complications of, 296 
degenerations of, 297 
abscess, 297 
angiomatous, 299 
calcareous infiltration, 297 
carcinomatous, 299 
cystic, 297 
hyaline, 297 
lipomyomatous, 299 
necrosis, 299 

sarcomatous, 299, 339, 346 
suppurative. 297 
diagnosis of, 306 

by abdominal examination, 307 
by bimanual palpation, 307 
interstitial, 307 
submucous, 307 
subperitoneal, 307 
differential diagnosis from cystic 
tumors of ovary, 308 
pelvic inflammatory masses, 
309 



740 



INDEX 



Myomata of uterus, differential diagnosis 
from pregnancy, 309 
solid tumors of ovary, 308 
enucleation, 311 
etiology of, 292, 303 

congenital anomalies in, 292 
racial element in, 292 
reproduction in, 292 
syphilis in, 292 
growth of, 295 
histology of, 292 
hysteromyomectomy in, 311, 317 

conservation of adnexa in, 312 
indication for operation in, 310 
myomectomy in, 311, 312, 314 
objections to, 311 
vaginal, 311 
operative technic of, 313 

abdominal myomectomy, 314 

for multiple myomata, 315 
hysteromyomectomy, 317 

with conservation of adnexa, 

322 
modifications of. 319-321 
treatment of cervical canal 
in, 324 
stump after, 323 
panhysterectomy, 324 

treatment of ureters in, 324 
vaginal myomectomy, 316 
origin of, 292 
panhysterectomy in, 313, 324 

with carcinoma of cervix, 313 
pressure effects of, 300 
on bladder, 300 
on nerves, 302 
on pelvic vessels, 302 
on rectum, 302 
on ureters, 301 
situation of, 294 
cervical, 294 
interstitial, 294 
intraligamentous, 294 
submucous, 294 
subperitoneal, 294 
subvesical, 294 
symptoms of, 304 
anaemia in, 303 
circulatory symptoms in, 306 
leucorrhcea, 305 
menorrhagia, 304 
metrorrhagia, 304 
causes of, 304 
pain, 305 

at menstruation, 305, 306 
from adhesions, 305 
from pressure, 305 
on defecation, 305 
on urination. 305 
referred to distant parts, 306 
severest, 305 
treatment of anaemia in, 310 
curettement in, 310 
for hemorrhage, 310 
operative, 311 



Myomata of uterus, treatment of, palliative, 
310 
radium in, 310, 718 
Rontgen ray in, 310, 718 
Myomectomy, abdominal, 314 

vaginal, 316 
Myometrium, 40 

N 

Nabothian cysts, 228, 230 
Nasal treatment in dysmenorrhcea, 590 
Nausea and vomiting, post-operative, exces- 
sive, 674 
treatment of, 674 
Nephrectomy, 484 
incisions for, 630 
in urinary fistulae, 468 
Nephritis, in operative cases, 618 
post-operative, etiology of, 684 
treatment of, 684 
Nephrolithotomy, 483 
Nephropexy, 483 
Nephroptosis, 509 
Nephrotomy, 483 

Nervous manifestations in pelvic disease, 101 
Neuroses, relation of, to pelvic diseases, 610 
prognosis in, 611 
treatment of, 611 

with acquired lesions of pelvis, 610 
without acquired lesions of pelvis, 610 
varieties of, 610 
New formations originating in embryonic 

rests, 9 
Nidation of ovum, y2 
Nitrous oxide, and oxygen anaesthesia, 650 

oxygen and ether anaesthesia, 650 
Normal support of perineum, mechanics of, 
200 
type of posture, 540 
Norris drain, in pathologic anteflexion of 
uterus. 243 
in treatment of dysmenorrhcea, 591 
Nose, applications to, in dysmenorrhcea, 590 
Nubility, 61 
Nuck, canal of, 48, 187 
Nurses, preparation of, for operations, 622 
Nymphae (see Labia Minora) 



Obesity, 550 

Obstruction of intestine, 505 
post-operative, 680 
Occupation in relation to pelvic disease, 93 
Oligomenorrhcea, 580 (see also Amenorrhoea) 
Omentum, in treatment of denuded surfaces, 

643 
Oophorectomy, 400, 435 
Oophoritis, acute interstitial, diagnosis of, 382 

chronic, 382 

end-results of, 382 

etiology of, 381 

pathology of, 381 

symptoms of, 382 

treatment of, 382 



INDEX 



741 



Operating room, lighting of, 623 

ventilation of, 623 
Operations during pregnancy. 656 
Operative area, exposure of, 637 
gauze pack in, 637 
isolation of. 636 
preparation of, 620 
technic. in abdominal incisions, 624 
closing the incision, 644 
drainage in, 639, 647, 657 
during pregnancy, 656 
gauze pack in, 637 
hsemostasis in, 640 
in dressing the incision, 646 
with drainage, 647 
in kidney operations, 630 
in multiple operations, 656 
in treatment of adhesions. 641 

of denuded surfaces, 643 
of incisions, 635 
of wounds of viscera, 642 
Operator, preparation of, for operation, 621 
Ovarian abscess, 381 

therapy in amenorrhcea, 581 
in artificial menopause, 596 
in dysmenorrhea, 590 
transplantation in sterility, 606 
heterografts in. 606 
homografts in, 606 
Ovariectomy, 400, 435 
Ovaritis. 381 
Ovary, abscess of, 381 
absence of, 15 
adenocystomata of, 384 
etiology of, 384 
pathology of, 384 
anatomy of, 42 
at birth, 6 
atrophy of, 408 

causes of, 409 
carcinoma of, diagnosis of, 395 
etiology of, 395 
metastatic, 408 
pathology of, 395 
symptoms of, 395 
changes in, at menopause, 82 
during menstruation, 69 
combined epithelial and connective-tissue 

tumors of, 397 
compound theca-lutein tumors of, 404 
connective tissue, new growths of, 396 
benign, 396 
fibromata, 396 

degenerations of, 396 
pathology of. 396 
malignant, 396 
sarcomata, 396 

Kruckenberg tumor, 

397 

pathology of, 396 
cystic degeneration of. 402 
cysts of, 383 

classification of, 383 
theories regarding histogenesis of, 
384 



Ovary, cysts of, with hydatid mole, 404 
daughter cysts of, 387 
dermoid cysts of, 383, 397 
origin of, 12, 397 
pathology of, 399 

thyroid tissue in, 399 
developmental anomalies of, 15 
effect of radium on, 719 

removal of, 595 
embryology of, 1 
epithelial new growths of, 384 
glandular cysts of, 384 

adenocystoma, 384 
diagnosis of, 389 
differential diagnosis of, from 
ascites, 391 
from fat, 391 
from myomata, 389 
from pregnancy, 389 
from tympanites, 391 
etiology of, 384 

theories of, 384 
papillomatous, 388 
pathology of, 384 
pseudomucinous, 388 
serous, 388 
symptoms of, 388 
grafts of, 606 
hernia of, 409 
hyperplasia of, 383 
hypertrophy of, 383, 409 
inflammation of, 381 (see also Peri- 
oophoritis) 
inflammatory diseases of, 382 
diagnosis of, 382 
symptoms of, 382 
treatment of, 382 
internal secretions of, 62, 63 
Kruckenberg tumor of, 397 
lymphatics of. 60 
malformations of, 15 
menopause and, 595 
mixed tumor of, 397 
mother cysts of, 387 
new growths of, treatment of, 399 
carcinoma, 401 
cystomata, 399 
during pregnancy, 401 
fibromata, 402 
intraligamentous cysts, 400 
papillomatous cysts, 401 
sarcomata, 402 
operations on, 404, 418, 435 
papillomatous cysts of, 393 

malignant degenerations of, 393 
pathology of, 394 
symptoms of, 394 
physiology of, 62 
prolapse of, diagnosis of, 409 
etiology of, 409 
symptoms of, 409 
treatment of, 409 
relation of, to glands of internal secre- 
tion, 62, 63 
retention cysts of, 402 



742 



INDEX 



Ovary, retention cysts of, corpus luteum 
cysts, 403 
cystic degeneration, 402 
diagnosis of, 403 
Graafian follicle cysts, 402 
hydrops folliculi, 402 
simple, 402 
symptoms of, 403 
treatment of, 403 

resection of ovary in, 404 
rudimentary, 15 
supernumerary, 15, 63 
syphilis of, 574 
teratomata of, 383 
thyroid tissue in, 399 
transplantation of, 606 
tuberculosis of, 565 
tumors of, accidents to, 405 
classification of, 383 
complicating pregnancy, 401 
complications of, 405 
connective-tissue type of, 383 
epithelial type of, 383 
infection of, 405 
malignant degeneration of, 407 
rupture of, 407 
causes of, 407 
results of, 407 
torsion of, 406 
cause of, 406 
treatment of, 406 
Ovula, Nabothi, 228, 230 
Ovulation, anatomic changes incident to, 70 

relationship of, to menstruation, 66, 69 
Ovum, nidation of, 72 



Pain in symptomatology of pelvic disease, 97 
Pampiniform plexus, 56 
Panhysterectomy, 313, 324 

for carcinoma of uterus, 324 
for myomata of uterus, 313 
treatment of ureters in, 324 
Wertheim's technic in, 349 
Paracolpium, 49 
Paracystium, 49 

inflammation of, 430 
Parametritis, 282, 419, 430 
Parametrium, 49 
Paraoophoron, 9 
Paraproctium, 49 

inflammation of, 430 
Pararenal tumors, 481 
Parasitic diseases of the external genitalia, 

106 
Parathyroid glands, relations of, to genera- 
tive organs, 64 
Paravaginitis, 193 
Parotitis, post-operative, 691 
Parovarian cysts, 391 

diagnosis of, 393 

differential diagnosis of, from 

myomata, 393 
etiology of, 11, 391 



Parovarian cysts, growth of, 392 

symptoms of, 392 
Parovarium, 9 

papillomatous cysts of, 393 

malignant degenerations in, 393 
Parturition (see Labor) 
Pathologic anteflexion of uterus, 237 
Paul's tube, 683 
Pediculosis pubis, 166 
Pelvic abscess, 428, 431 

adhesions, treatment of, 641 
arteries, 54 
bacteriology, 88, 411 
cellular tissue, 48 

syphilis of, 575 
cellulitis, 430 (see also Cellulitis, Pelvic) 
connective tissue, 48 
diseases, onset of, 96 

relation of neuroses to, 610 
examination, by inspection, 125 
by palpation, 125 
bimanual, 126 

with cervix pulled down, 129 
with finger in rectum, 129 
simple digital, 126 
trimanual, 130, 131 
local physical, 112 

under anaesthesia, 112 
floor, fascia of, 53 
injuries to, 200 
muscles of, 50 

physiology of support of, 200 
triangular ligament of, 53 
inflammatory disease, acute, 411 

chronic, 428 (see also Chronic 
Pelvic Inflammatory Disease) 
classification of, 411 
etiology of, 411 
factors in etiology of, 412 
gonorrhceal, 412 (see also Gon- 
orrhceal Pelvic Inflammatory 
Disease) 
in etiology of dysmenorrhea, 589 
instrumental, 425 (sec also Post- 
operative Pelvic Inflammatory 
Disease) 
pathology of, 411 
post-operative, 425 (see also 
Post-operative Pelvic Inflam- 
matory Disease) 
puerperal, 419 (see also Puer- 
peral Pelvic Inflammatory 
Disease) 
treatment of, operative technic 
in, 433 
hysterectomy, 433 
salpingectomy, 437 
salpingo-oophorectomy, 436 
salpingostomy, 438 
vaginal incision and drain- 
age, 438 
use of heat in, 700 

Gelhorn's method of, 
700 



INDEX 



743 



Pelvic ligaments, 46 

lymphatics of, 58 

massage in chronic pelvic cellulitis, 433 

peritoneum, 45 

veins, 56 
Pendulous abdomen, 550 
Percussion, trimanual method of, 134, 393 
Percy's method in carcinoma of cervix, 354, 

355 
Perforation of uterus, accidents in, 287 
etiology of, 287 
injury to intestine in, 287 
symptoms of, 287 
treatment of, 287 
Perimetritis, 430 

Perineal operations, preparations for, 620 
Perineorrhaphy, 209, 210, 213 
Periodic intermenstrual pain, 592 
Perioophoritis, diagnosis of, 382 
end-results of, 382 
etiology of, 381 
pathology of, 381 
symptoms of, 381 
treatment of, 381 
Perineum, injuries to, 200 
forms of, 200 

immediate, 200 
remote, 200 
mode of production of, 201 
results of, 200 
lacerations of, 201 
complete, 202 

symptoms of, 207 
lateral, 201 

effects of, 201 
median, 201 

operations for, complete tear of, 214 
Emmet, 209, 210 
Hegar, 211 
relaxation of, diagnosis of, 205 
treatment of, 204, 208 
Perisalpingitis, 360, 361 
end-results of, 365 
Peritoneum, of pelvis, 45 

abdominal, tuberculosis of, 563 
Peritonitis, post-operative, 675 
diagnosis, 677 
localization of, 676 
symptoms, 676 
treatment of, 678 
Pessaries, use of, 702 
care of, 704 
disk, 702 
fitting of, 250 
Hodge, 701 

indications for, 250, 251, 269, 270, 702 
Menge, 703 
Smith, 701 
soft rubber, 702 
types of, 702, 703 
Pfannensteil's theory of histogenesis of 

ovarian cysts, 384 
Pfluger's tubules, 384 

Phenolphthalein, estimation of elimination of, 
160 



Phenolphthalein in kidney function test, 159 
Phlebitis, etiology of, 686 
placental, 420 
post-operative, 686 
treatment of, 687 
Physical examination, in pelvic disease, 103 
Physiology of generative organs, 61 
Physometra, etiology of, 288 
symptoms of, 288 
treatment of, 288 
Pick's theory of histogenesis of ovarian 

cysts, 384 
Pineal gland, relationship of, to generative 

organs, 65 
Pituitary body, extract of, in shock, 670 

relationship of, to generative organs, 
63 
Placenta, formation of, 73 

relationship of, to generative organs, 65 
Placental thrombophlebitis, 420 
Placentation, 73, 75 

Plastic operations (see Colporrhaphy, Perine- 
orrhaphy and Trachelorrhaphy) 
hemorrhage after, 673 
Pleurisy, post-operative, 684 
Polycystic disease of kidney, 480 
Polyps of rectum, 532 
Position, dorsal, 113 
erect, 116 

for examinations, 113 
knee-chest, 114, 115 
recumbent, 116 
Sims', 115 
supine, 116, 117 
Posture, after operations, 668 
errors in, 539 
Fowler, 669 
in cardiac cases, 615 
normal type of, 540 
Trendelenburg, 669 
Post-operative care of drainage cases, 661 
complications, acidosis, 692 

acute gastric dilatation, 682 

bronchitis, 683 

cardiac dilatation, 690 

cystitis, 690 

hemorrhage, 671 

intestinal obstruction, 678 

nausea and vomiting, 674 

nephritis, 684 

parotitis, 691 

peritonitis, 675 

phlebitis, 686 

pleurisy, 684 

pulmonary, embolism, 688 

renal infection, 689 

shock, 670 

suppression of urine, from ureteral 

obstruction, 685 
suppuration in incision, 689 

in pelvis, 690 
tympanites, 674 
pelvic inflammatory disease, 425 
etiology of, 425 
pathology of, 425 



744 



INDEX 



Post-operative pelvic inflammatory disease, 
symptoms of, 426 
treatment of, 427 

operative measures in, 427 
palliative measures in, 428 
vaginal puncture in, 428 
treatment, of bladder, 665 
diet in, 664 
dressing incision, 669 
enteroclysis in, 667 
nausea, 663 
of bowels, 664 
pain, 663 
posture, 668 
thirst, 663 
vomiting, 663 
Pouch of Douglas, 46 
Pozzi's operation in pathologic anteflexion of 

uterus, 243 
Precancerous changes in uterus, 343 
Precocious menstruation, 579 
Pregnancy, complicated by appendicitis, 656, 

657 
by ovarian cysts, treatment of, 401 
corpus luteum of, 76 
diagnosis of, from myomata, 309 

from ovarian cysts, 389 
Hegar's sign of, 76 
in relation to pelvic disease, 94 
in retroverted uterus, 656 

treatment of, 253, 254, 656 
operations during, 401, 656 
pyelitis in, 486, 487 
Premature menopause, 594 
Preparation of, for operation, assistants, 
catgut, 622, 623 
dressings, 622 
furniture, 62^ 
gloves, 622 
hands, 622 

for pelvic examination, 117 
instruments, 623 
nurses, 622 
operating room, 623 
operative area, 620 

for abdominal operations.. 621 
for perineal operations, 620 
patients, 613, 621 
Preparatory measures in hysterectomy, 345 

in operative cases, 614 
Procidentia uteri, 238, 263 
Proctoscopes, Kelly, 164 

Tuttle, 163 
Proctoscopic examination of rectum, 163 
Prolapse of ovary, 409 
of rectum, 532 

of the urethral mucosa, 446, 447 
of uterus, 238, 263 
Pruritis ani, 527 
vulva, 169-171 

radium in, 721 
Pseudoamenorrhcea, 580 
Pseudohermaphrodism, female, 22 

male, 23 
Pseudomucin, 388 



Pseudomyxomata ovarii, 407 

oeritoneii, 407 
Ptosis of intestines, 507 

of kidney, 469 
Puberty, age of, 61 

influences affecting, 61 
manifestations of, 61 
ovarian development at, 62 
Puerperal pelvic inflammatory disease, 419 
diagnosis of, 421 

examination in, 421 
of pelvic lesions in, 421 
end results of, 422 
etiology of, 419 

gonococcus in, 419 
streptococcus in, 419 
mode of invasion 
of, 419 
pathology of, 420 
pelvic abscess in, 422 

lesions resulting 
from, 420 
prognosis, 421 

factors influencing, 421 
symptoms of, 420 
treatment of, 422 

arseno-benzol in, 424 
exploration of uterus in, 

423 
horse serum in, 424 
palliative measures in, 

422 
sera in, 424 
tamponade of uterus 

in, 423 
vaccines in, 424 
vaginal puncture in, 425 
Puerperium, pyelitis in, 485 
Pulmonary diseases, post-operative, 683 
in etiology of pelvic disease, 106 
embolism, 688 
Pulse in pelvic disease, 104 
Pyelitis, bacteriology of, 486 
etiology of, 485 
in pregnancy, 486 
pathology of, 485 
prognosis of, 486 
symptoms of, 486 
treatment of, 487 
vaccines in, 488 
Pyelography, death following, 157 

in diagnosis of movable kidney, 469 
in hydronephrosis. 471 
in kidney disease, 157 
in ureteral calculus, 157 

obstruction, 157 
solutions for, 156. 158 

preparation of, 156 
technic of, 156 
Pyelonephritis, 471 
etiology of, 471 

hematogenous infection in, 471 
urinary passages, infection of, in, 

47i 
pathology of, 471 



INDEX 



745 



Pyelonephritis, symptoms, 472 

treatment of, 473 

operations in, 473 
Pyelonephrosis, 471 
Pyelotomy, 483 
Pyometra, etiology of, 288, 335 

symptoms of, 288 

treatment of, 288 
Pyosalpinx, 360-362 

infectiousness of contents, 363, 365 

rupture of, 368 



Radium, combined with Rontgen ray, 716 
complications following use of, 715 
distance of effect of, 714 
dose of, 715 
effect of filters on, 714 

upon ovaries, 719 
fistula following use of, 715 
histological changes in tissue after use of, 

714 
in abdominal tumors, 72^ 
in carcinoma of cervix, 341, 714 

complicating myomata, 313 
in early cases, 714 
of fundus, 346, 717 

indications for, 717 
of ovary, 402 
of urethra, 452 
of vagina, 197 
of vulva, 721 
in carcinomata of bladder, 461, 721 
results of, 721 
technic of using, 722 
in chorioepithelioma of uterus, 349 
in chronic metritis, 284 
in diseases of rectum, 722 
in hemorrhagic uteri, 720 
advantages of, 720 
curettage in, 721 
results of, 721 
Rontgen ray in conjunction with, 

720 
technic of using, 720 
varieties influenced by, 720 
in myomata of uterus, 717 
advantages of, 718 
complications in, 720 
contraindications for use of, 718 
disadvantages of, 717 
effects of, 717, 719 
indications for use of, 718 
results of, 719 
technic of, 719 
in papillomata of bladder, 721 

results of, 721 
in pruritus vulva. 72^ 
in treatment of bladder tumors, 460 
method of use of, 714 
physical properties of, 713 
radiations of, 713 
resistance of tissues to, 713 
standard of, 713 



Radium, resistance of tumor cells to, 713 
results of, 714 
statistics in, 715, 716 
Reaction, Abderhalden, 107 

complement-fixation for gonorrhoea, 107 

for syphilis, 108 
Wassermann, 108 
Recto-abdominal examination of pelvic or- 
gans, 129 
Rectocele, mode of production of, 202 
Rectum, anatomy of, 45 

carcinoma of, 534 (see also Carcinoma 

of Rectum) 
diseases of, radium in, 722 
embryology of, 2 
examination of, 162 

by proctoscope, 164 
by sigmoidoscope, 165 
by specula, 163 
irritability of, in extrauterine pregnancy, 

8 5 
malformations of, 21 
treatment of, 259 
polyps of, 533 

prolapse of, diagnosis of, 532 
etiology of, 530 
symptoms of, 531 
treatment of, 532 

Moschcowitz plan in, 532 
operations in, 532 
stricture of, 535 
tumors of, 534 
Renal, blastema, 6 

calculus, diagnosis of, 479 
etiology of, 478 
pathology of, 478 
treatment of, 480 

operations in, 480 
findings, no 

infection, post-operative, etiology of, 689 
sufficiency, test for, no 
Resection of Fallopian tube, 418 

in gonorrhceal pelvic inflammatory dis- 
ease, 418 
technic of, 418 
of ovary, 404 
Respiration in pelvic disease, 105 
Respiratory symptoms in pelvic disease, 101, 

106 
Retarded menstruation, 580 
Retrodisplacements of uterus, 244 (see also 

Uterus, Displacements of) 
Retroversion of uterus, 237-244 (see also 

Uterus, Retroversion of) 
Reynolds' observations on spermatozoa in 

diagnosis of sterility, 603 
Ringworm of external genitalia, 166 
Rodent ulcer of vulva, 184 
Rontgen ray, in abdominal tumors, 723 

in carcinoma of the cervix with 
radium, 716 
of the ovary, 402 
of the vulva, 721 
in diagnosis of myomata, 309 



746 



INDEX 



Rontgen ray, in diagnosis of vesical calculus, 
458 
in examination of the kidney, 151, 
152 
of renal calculi, 153, 479 
of ureteral calculus, 156, 491 
in hemorrhagic uteri, 720 
in myoma ta of uterus, 717 
advantages of, 718 
contraindications to, 718 
disadvantages of, 717 
effects of, 718 
indications for, 718 
in pruritus vulva, 721 
in pyelography, 157 
in treatment of carcinoma of body of 
uterus, 346 
of menorrhagia, 584 
of metrorrhagia, 585 
of myomata, 310 
of tuberculosis of vulva, 567 
of vulvitis, 171 
in vulvar lesions, 721 
therapy, 713 
Rosenmiiller, organ of, 13 
Rosenow's observations on etiology of oopho- 
ritis, 381 
Rupture of ovarian cyst, 407 
of tubal enlargements, 368 

pregnancy, 375 
of uterus, 287 
of varicose veins in broad ligament, 433 



Sacroiliac sprain, diagnosis of, 548 

differentiation of, from static back- 
ache, 543 

etiology of, 546 

examinations in, 548 

prognosis of, 550 

symptoms of, 547 

treatment of, 548 
Sactosalpinx, 367 
Salpingectomy in pelvic inflammatory disease, 

437 
Salpingitis, 359 

and ovarian abscess, 365 
diagnosis, 415 (see also Pelvic Inflamma- 
tory Disease) 
differential diagnosis from appendicitis, 

414 

etiology of, 359 _ 

gonococcus in, 359 

mode of invasion of infecting or- 
ganism, 359 

relative frequency of infecting or- 
ganisms, 359 
interstitial, 361 
isthmica nodosa, 361, 418 
pathology, 359 

bilateral involvement, 360 

endosalpingitis, 359, 360 

hydrosalpinx in, 360 

interstitial changes in, 360, 361 



Salpingitis, pathology, perisalpingitis, 360, 361 
pyosalpinx in, 360 
unilateral involvement, 360 
with various infecting organisms, 360 
symptoms (see Pelvic Inflammatory 

Disease) 
treatment (see Pelvic Inflammatory 

Disease) 
tuberculous, 561 (see also Tuberculosis of 
Tubes) 
Salpingo-oophorectomy for pelvic inflamma- 
tory disease, 436 
Salpingostomy, 418, 419 

in pelvic inflammatory disease, 438 
Sanger's operation for cystocele, 216 
Sarcoma of ovary, 396 
of uterus, 346 
of vulva, 183 

radium in, 721 
Schatz pessary, 703 
Selection of cases for operation, 613 
of operations of urgency, 613 

of election, 613 
of patients for operation, 613 
of time of operation in pelvic inflamma- 
tory disease, 613 
Serum, auto-therapy, 725 
dose in, 725 
in puerperal inflammatory pelvic disease, 

424 
preparation of, 725 
specific, 725 
therapy, 725 
Sexual gland, 1, 42 

maturity, 61 
Shock, post-operative, cause of, 670 
diagnosis of, 670 
symptoms, 670 
treatment of, 670 
Simpson's operation in retroversion, 261 

technic of, 262 
Sims' curette, 121 
position, 115 
speculum, 117 
Skene's ducts, 33 

infection of, 440 
tubules, applications to, 701 
Smear preparations as an aid to diagnosis, 123 
Smith, pessary, 702 
Social state in relation to disease, 91 
Specific therapy in gynecology, 725 
Spermatozoa in diagnosis of sterility, 601-603 
Sphincter ani muscle, divulsion of, for fissure, 
523 
lacerations of, 202 
effect of, 202 
repair of complete tear of, 215 
Spinal anaesthesia in pelvic surgery, 652 
Babcock's plan in, 653 
deaths from, 654 
determination of dosage in, 

654 
in abdominal operation, 653 
indications for, 652 



INDEX 



747 



Spinal anaesthesia in pelvic surgery, solutions 
for, 653 
technic of, 653 
Spirochete pallidum, demonstration of, 124, 

1/4 
Sponges, use of, in abdominal surgery, 648 
Static backache, diagnosis of, 540 

recording tracing in, 540 
differential diagnosis in, 542 
from pelvic disease, 542 
from sacroiliac disease, 542, 543 
from spinal disease, 543 
etiology of, 538 

faulty posture in, 539 

flat foot in, 538 

pelvic disorders in, 538 

tumors in, 539 
pendulous abdomen in, 539 
skeletal defects in, 539 
symptoms of, 539 
treatment of, general, plan of, 543 
diet in, 546 
orthopaedic, 543 

corsets in, 543, 544 
exercises in, 546 
shoes in, 543 
Sterility, absolute, 598 

as symptom of pathologic anteflexion of 

uterus, 240 
definition of, 598 
diagnosis of, 601 

examination of male in, 601 
Hiihner's method in, 601, 602 
Reynolds' observations in, 603 
spermatozoa in, 601, 602 
etiology of, 601 

functional defects in, 601 
gonococcus infections in, 554, 600 
one-child sterility, 598 
relative, 598 

responsibility of male and female in, 
600 
treatment of, 603 

artificial insemination in, 606 
of developmental defects in, 604 
of gross pelvic diseases in, 605 
of inflammatory diseases of the lower 

genital tract in, 604 
ovarian transplantation in, 606 
posture in, 607 
time of coitus in, 607 
Stiles' operation in urinary fistula, 468 
Stitch abscess, 691 

Stomach, acute dilatation of, post-operative, 
684 
operations on, 515 
Streptococcus, in pelvic inflammatory disease, 
411 
infection in carcinoma of the cervix, 335 
mode of invasion of pelvic organs by, 89, 
420 
Stricture of the rectum, diagnosis of, 535 
etiology of, 535 
pathology of, 535 



Stricture of the rectum, treatment of, 535 
of the ureter, diagnosis of, 497 
etiology of, 495 
pathology of, 496 
symptoms of, 495 
treatment of, 497 

operations in, 497 
of the urethra, diagnosis of, 449 
etiology of, 449 
symptoms of, 449 
treatment of, 449 
Struma ovarii, 399 

Subinvolution of uterus, etiology of, 285 
symptoms of, 285 
treatment of, 285 
Suburethral abscess, 445 
Support of perineum, normal, mechanics of, 

200 
Suppression of urine from ureteral obstruc- 
tion, post-operative, 685 
Suppuration, of incision, post-operative, 691 
in pelvis, post-operative, 691 
etiology of, 691 
treatment of, 692 
Suprarenal gland, in relation to genital or- 
gans, 64 
glands, relationship of, to generative or- 
gans, 64 
tumors, 481 
Suspension of kidney, 482, 483 
Symptomatology, 91 

circulatory disorders in, 101 
constipation in, 100 
gastro-intestinal disorders in, 100 
general health in, 101 
headache in, 99 
leucorrhcea in, 99 
menstruation in, 98 
nervous manifestations in, 101 
pain in, 97 
Syncytium, 73 

Syphilis, in chronic metritis, 282 
in myomata, 292 
of the cervix, 572 

differential diagnosis of from, 
aphthous ulcers, 577 
carcinoma of cervix, 577 
chancroid, 576 
gonorrhoeal macules, 576 
herpes genitalis, 577 
myomata, 577 
tuberculous ulcers, 576 
primary lesion in, 572 
secondary lesion in, 573 
tertiary lesion in, 573 
of the Fallopian tube, 574 
of the generative organs, 569 
diagnosis of, 575 
factors in difficulty in establish- 
ing diagnosis, 569 
general considerations of, 569 
mode of infection, 569 
pathological findings in, 569, 570 
prognosis of, 578 



748 



INDEX 



Syphilis of the generative organs, symptoms 
of, 569 
treatment of, 578 
of the ovary, 574 
of the pelvic cellular tissue, 575 
of the uterus, 574 
of the vagina, 572 
of the vulva, 174, 571 

primary lesion in, 174, 571 

varieties of, 571 
secondary lesion in, 174, 571 
condylomata lata, 571 
varieties of, 571 
tertiary lesions in, 571 
gumma in, 571 
organism of, demonstration of, 124 



Temperature in pelvic disease, 103 
Thermo-cautery, 704 
Thrombophlebitis, placental, 420 
Thyroid tissue in ovary, 399 

gland, relationship of, to generative or- 
gans, 64 
Time of getting out of bed after operations, 

669 
Trachelectomy, 234 

indications for, 232 
Trachelorrhaphy of Emmet, 233 

indication for, 232 
Transplantation of ovaries, 606 
Treatment of patients preparatory to opera- 
tion, 614 
Trendelenburg position, 669 
Treponema pallidum, demonstration of, 124 
Triangular ligament of pelvic floor, 53 
Trimanual method of percussion, 130 
Toxic arthritis, 550 
Tuberculosis, of cervix, 566 
of the endometrium, 564 
of the generative organs, 89, 560 
manifestations of, 560 
primary, 560 

relative frequency of, 560 
secondary, 560 

site of, relative frequency of, 560 
of the kidney, 473 
diagnosis of, 475 

animal inoculations in, 475 
etiology of, 473 
pathology of, 473 
prognosis of, 478 
symptoms of, 475 

cystoscopy in, 457, 476 
urine in, 476 
treatment of, 477 

operations in, 478 
of the ovary, pathology of, 565 
symptoms of, 565, 566 
treatment of, 566 
of the peritoneum, etiology of, 563 
pathology of, 563 

varieties of, 563 
Symptoms of, 563 



Syphilis of the peritoneum, treatment of, 564 
of the tubes, diagnosis of, 562 

pathology of, primary form of, 561 

secondary form of, 561 
symptoms of, 562 
ascites in, 562 
treatment of, 562 
of the vagina, 566 
of the vulva, diagnosis of, 567 
differential diagnosis of, 567 
from chancroid, 567 
from carcinoma, 567 
from syphilis, 567 
pathology of, 567 
symptoms of, 567 
treatment of, 567 
Tubo-ovarian abscess, 365 

cyst, 366, 367 
Tubules, Kobelt's, 11 
paraurethral, 34 
Pfiiiger's, 385 
Skene's, 700 
Tunica albuginea, 1 
Tympanites, post-operative, 674 
treatment of, 674 



U 

Urachus, cyst of, 21 

Urea, in blood, method of determining, 160 
Ureter, anatomy of, 43 
calculus in, 489 

diagnosis of, 156 

shadow catheter in, 156 
catheterization of, 147 
by direct method, 148 
by indirect method, 148 
in pyelitis, 487 
reflex anuria in, 150 
collection of urine from, 149 
diseases of, 469 
displacements of, 147 
embryology of, 3 
examination of, by wax-tipped bougie, 

inflammation of, 489 
in hysterectomy, 324 
injuries to, 642 
inspection of orifice of, 142 
ligation of, 643 
malformations of, 21 

absence of, 21 

duplication of, 21 

fistula of, 21 

occlusion of, 21 
obstruction of, 149, 497, 686 

suppression of urine by, 686 

symptoms of, 498 

treatment of, 498 
orifices of, position of, 147 

locating by chromo-ureterocysto- 
scopy, 159 
palpation of, 138 
physiology of, 84 



INDEX 



749 



Ureter, relation of, to uterine artery, 44 
stone in, 489 

stricture of, 495 (see also Stricture of 
Ureter) 
Ureteral, calculus, diagnosis of, 490 
methods in, 490 
differential diagnosis of, from appen- 
dicitis, 490 
etiology of, 489 
pathology of, 489 
sequelse of, 490 
symptoms of, 490 
treatment of, 492 

operations in, 493 

extraperitoneal, 495 

for stone at pelvic brim, 

493 

in the intraparietal 

ureter, 494 
in upper ureter, 493 
in vesical portion, 493 
per vaginam, 495 
catheters, sterilization of, 143 
bismuth, 156 
shadow, 156 
colic, 490 

differentiation of, from appendicitis, 

490 
treatment, 492 
obstruction, post-operative, 686 
stricture, 495 

anastomosis in, 468 
Ureteritis, diagnosis of, 489 
symptoms, 489 
treatment, 487, 489 
Uretero-rectal anastomosis in urinary fistula, 

468 
Uretero-ureteral anastomosis in urinary fis- 
tula, 468 
Uretero-vaginal fistula, 463 
Urethra, abscess of, 445 
anatomy of, 43 
application to, 700 
carcinoma of, 451 
caruncle of, 449 
developmental anomalies of, 21 
dilatation of, 447 
diseases of, 440 
embryology of, 2 
fissure of, 445 
inflammation of, 440 
inspection of, 140 
local anaesthesia for, 650 
mucosa of, prolapse of, 446 
new growths of, 451 
palpation of, 138 
physiology of, 84 
stricture of, 449 
Urethral caruncle, diagnosis of, 449 
symptoms of, 449 
treatment of, 450 
dilatation, diagnosis of, 448 
etiology of, 447 
symptoms of, 448 
treatment of, 448 



Urethral dilatation, treatment of, operations 

in, 449 
Urethritis, acute gonorrhceal, 440 
diagnosis of, 440 
prognosis of, 440 
symptoms of, 440 
treatment of, 440 
types of, 441 
chronic gonorrhceal, 441 
diagnosis of, 442 
local treatment in, 443 
symptoms of, 442 
treatment of, 443 
types of, 444 
Urethroscopy, 140 
Urethro-vaginal fistula, 463 
Urinalysis, 108, 138 
Urinary, fistula, diagnosis of, 465 
etiology of, 463 
prognosis of, 465 
symptoms of, 463 
treatment of, 466 

extraperitoneal abdominal, 468 
nephrectomy in, 468 
operations in, 466 
vaginal operations in, 467 
Ward's plan in, 466 
varieties, 463 
organs, examination of, 138 

symptoms in pelvic disease, 100 
Urination, mechanics of, 84 
Urine, bacteria of, 109 

bacteriologic examination of, 100 
collection of, from ureters, 149 
examination of, for tubercle bacillus, ill 
incontinence of, 447, 448 
in pelvic disease, 108 
Uterus, abscess of, 282 

adenomyoma of, 326 (see also Adeno- 

myoinata of Uterus) 
anatomy of, 36 
anteflexion of, 237 
anteposition of, 273 
at birth, 8 
carcinoma of, 330 (see also Carcinoma of 

Uterus) 
changes in form of, 237 

in position of, 237 
chorioepithelioma of, 346 (see also 

Chorioepithelioma of Uterus) 
descensus of, 238, 263 

accompanying lesions, 266 
diagnosis of, 268 
etiology of, 265 
mechanics of, 263 
symptoms of, 268 
treatment of, 268 
by pessaries, 269 
Menge pessary in, 270 
operations in, 270 
developmental anomalies of, 15, 18, 25, 
288 
bicornis, 17 

congenital dwarfing, 17 
duplex bicornis, 16, 26 



750 



INDEX 



Uterus, developmental anomalies of, duplex 
septus, 17 
subseptus, 17 
fcetalis, 17 
infantilis, 18 
latero-position, 18 
retroflexion, 18 
retroversion, 18 
unicornis, 16 
during childhood, 8 
elevation of, 238, 273 
embryology, 2 

exploration of, in puerperal pelvic in- 
flammatory disease, 423 
with sound, 19 
gas in, 288 (see also Physometra) 
hypoplasia of, 240 
hernia of, 238 

hyperinvolution of, 286 (see also Hyper- 
involution of Uterus) 
inflammation of, acute, 282 

chronic, 282 
interposition of, for cystocele, 220 
inversion of, 274 
latero-position of, 237, 273 
ligaments of, 46 
lymphatics of, 60 
malformations of, 25 
diagnosis of, 25 
didelphys, 26 
treatment of, 28 
malignant tumors of, 330 
myomata of, 292 (see also Myomata of 

Uterus) 
normal position of, 237 
pathologic anteflexion of, associated con- 
ditions with, 239 
diagnosis of, 241 
Dudley's operation for, 243 
Norris drain in, 243 
Pozzi's operation in, 243 
prognosis of, 241 
symptoms of, 240 
treatment of, 242 
varieties of, 239 
flexion of, 237 
position of, 237 
perforation of, 287 (see also Perforation 

of Uterus) 
precancerous changes in, 343 
prolapse of, 238, 263 (see also Descensus 
of Uterus) 
treatment of, 268 
by pessaries, 269 
cervix, attention to, in, 271 
choice of operations in, 270 
interposition operation, 272 
Menge pessary in, 270 
operations in, 270 
supravaginal hysterectomy in, 

vaginal fixation in, 272 
ventral fixation in, 271 
physiology of, 63 



Uterus, procidentia of, 238, 266 (see also De- 
scensus of Uterus) 
pus in, 238 (see also Pyometra) 
retroflexion of, 237, 244 (see also Retro- 
version of Uterus) 
retroposition of, 273 

retroversiofiexion of (see also Retro- 
version) 
retroversion of, 244 
causes of, 244 
diagnosis of, 247 
in pregnancy, 253, 657 

treatment of, 253, 659 
mechanics of production of, 203 
symptoms of, 246 
treatment of, 247 

Alexander operation in, 254, 260 
Coffey operation, 258, 261 
knee-chest position in, 250 
manual "replacement of, 249 
operations in, 254 

test of, 258 
pessaries in, 250-253 
replacement of uterus in, 248 
round ligament operations in, 258 
shortening of utero-sacral liga- 
ments in, 263 
Simpson operation in, 261 
uterosacral ligaments in, 263 
ventrofixation in, 261 
ventrosuspension in, 257, 260 
Webster-Baldy operation in, 259, 
262 
varieties of, 244 
sarcoma of, 346 
subinvolution of, 285 
syphilis of, 574 
torsion of, 274 
Uterine, intra-, digital palpation, 119 
pack, 705 
sound, 119 
Utero-vaginal tract, congenital dwarfing of, 
17 

V 

Vaccine therapy, dosage in, 726 

gonococcus, 725 

in arthritis, 726 

in leucorrhcea, 199 

in pelvic inflammatory disease, 725 

in puerperal pelvic inflammatory dis- 
ease, 425 

in pyelitis, 488 

in vaginitis of infants, 725 

in vulvo-vaginitis, 725 

mixed, 725 

reactions to, 726 

diagnostic value of, 726 
Vagina, anatomy of, 34 

artificial formation of, 28 
at birth, 8 
bacteriology of, 89 
Baldwin's operation on, 28 
carcinoma of, 196 
chorioepithelioma of, 197 



INDEX 



751 



Vagina, cysts of, 194 

developmental anomalies of, 25 
absence of, 18 
atresia of, 18 
defectus vagina, 18 
double, 18, 26 
septate, 19 
unilateral, 18 
diseases of, 192 
embryology of, 2 
fibromyoma of, 195 
foreign bodies in, 197 
inflammation of, 192 
local applications to, 699 
lymphatics of, 60 
malformations of, 25 

diagnosis of, 25 
physiology of, 62 
sarcoma of, 196 

grape-like, 196 
syphilis of, 572 
tuberculosis of, 566 
Vaginal, douche, indications for, 706 
method of giving, 707 
solutions for, 707 
drainage, 659 

examination of pelvic organs, 126 
fixation for descensus and prolapsus of 

uterus, 272 
incision and drainage, 659 

local anaesthesia for, 651 
operations in urinary fistula, 467 
pack, 705 
puncture, in extrauterine pregnancy, 379, 

659 

in gonorrhceal pelvic inflammatory 

disease, 416, 438 
in pelvic abscess, 428 
in puerperal pelvic inflammatory dis- 
ease, 425 
technic of, 427 
tampon, medicaments for, 709 

in chronic pelvic cellulitis, 433 
methods of using, 709 
uses of, 708 
vaults, 34 
Vaginismus, 172, 194 
treatment of, 194 
Vaginitis, 192 
acute, 192 
chronic, 192 
gonorrhceal, 193 
senile, 193 
subacute, 192 
symptoms, 192 
treatment, 192, 193 ■ 
by lactic acid, 198 
Van Hook's method of ureteral anastomosis, 

492 
Varicose veins of broad ligament, rupture of, 

433 
of vulva, 180 
Venereal sores, 173 
warts, 178 



Ventrofixation of uterus, in retroversion, 261 
Ventrosuspension in retroversion, 257, 260 
Vesical calculus, diagnosis of, 458 
etiology of, 458 
Rontgen ray in, 458 
symptoms of, 458 
treatment of, 459 

operation in, 459 
vesico-vaginal fistula, 459 
Vesico-cervical fistula, 463 
Vesico-vaginal fistula, 463 
in cystitis, 456 

in treatment of vesical calculus, 459 
Vestibule, 33 

Vicarious menstruation, 580 
Virgins, examination of, 112, 610 
Visceroptosis, associated with prolapse of 

uterus, 265 
Vulva, adhesions of, 167 
anatomy of, 31 
atresia of, 20 
carcinoma of, 181 
chancre of, 174 
chancroid of, 176 
condylomata of, 178 
developmental anomalies of, 20 
double, 20 

elephantiasis of, r.73 
fibromyoma of, 185 
gonorrhceal inflammation of, 169 
hematoma of, 180 
hyperesthesia of, 172 
hypertrophy of, 180 
infantile, 20 
inflammation of, 167 
kraurosis of, 172 
lipoma of, 186 
lupus of, 183 
lymphatics of, 60 
oedema of, 179 
pruritis of, 169 

radium in, 722 
rodent ulcer, 184 
sarcoma of, 183 
sebaceous cysts of, 186 
syphilis of, 571 

syphilitic eruptions on, 174, 175 
tuberculosis of, 183, 567 
varicose veins of, 180 
Vulvar, incisions, local anaesthesia in, 652 
Vulvectomy, 182 
Vulvitis, 167 

Vulvo-vaginitis, of children, treatment of, 169 
vaccines in, 169 
gonorrhceal, 169 

treatment of, 169 
Vulvo-vaginal glands, abscess of, 186 
treatment of, 186, 187 
cysts of, 187 
inflammation of, 186 

W 

Waldeyer's theory of histogenesis of ovarian 
cysts, 384 



752 



INDEX 



~% 



Walthard's theory of histogenesis of ovarian 

cysts, 384 
Ward's operation in urinary fistula, 466 
Wassermann reaction, in pelvic disease, 107 

in vulvar diseases, 174 
Watkins' operation for cystocele, 220 

in prolapse of the uterus, 272 
Webster's operation in retroversion of uterus, 

259 
hsemostasis in, 640 
in prolapse of uterus, 410 
technic of, 262 
Wertheim's panhysterectomy for malignant 

disease of uterus, 349 
Williams' theory of histogenesis of ovarian 
cysts, 384 



Wilms' operation for intestinal stasis, 516 
Wolffian body, 1 

in etiology of adenomyoma, 327 
duct, 1 
glomeruli, in etiology of pseudomucinous 

cysts of the ovary, 388 
tubules, in ovarian cysts, 384 

in etiology of carcinoma of ovary. 
395 
of paraovarian cysts, 391 
Wounds of viscera, treatment of, 642 



X 



X-ray (see Rontgen Ray) 



AUG ~i 



\0t 



•A 



